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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Material and Methods
 ::  Results
 ::  Discussion
 ::  Conclusions
 ::  Acknowledgement
 ::  References
 ::  Article Figures
 ::  Article Tables

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ARTICLE
Year : 1978  |  Volume : 24  |  Issue : 1  |  Page : 32-39

Role of mannitol in cataract surgery


Department of Ophthalmology, K.E.M. Hospital and Seth G.S. Medical College, Parel, Bombay-400 012., India

Correspondence Address:
B T Shah
Department of Ophthalmology, K.E.M. Hospital and Seth G.S. Medical College, Parel, Bombay-400 012.
India
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PMID: 731610

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 :: Abstract 

Hypertonic mannitol solution has been found to be most effec­tive in preventing vitreous loss in cataract surgery due to profound hypotony and detergence of vitreous following intravenous in­fusion. Routine use of mannitol is hence recommended prior to cataract surgery, especially in all one-eyed patients or in cases where there is an increased risk of vitreous disturbances.



How to cite this article:
Shah B T, Maskati B T. Role of mannitol in cataract surgery. J Postgrad Med 1978;24:32-9

How to cite this URL:
Shah B T, Maskati B T. Role of mannitol in cataract surgery. J Postgrad Med [serial online] 1978 [cited 2014 Jul 30];24:32-9. Available from: http://www.jpgmonline.com/text.asp?1978/24/1/32/42684



 :: Introduction Top


Osmotic agents like urea, mannitol, gly­cerol have been effectively used earlier to lower both the cerebro-spinal pressure and intra-ocular pressure. Mannitol is a hexahydroxy alcohol related to mannose. It occurs as a white, crystalline powder and is soluble in water and stable at room temperature. Intravenous administration of mannitol induces diuresis by elevating the osmotic pressure of the glomerular filtrate to such an extent that tubular re-absorption of water and sodium is hinder­ed. Mannitol also promotes excretion of chlorides. It itself is excreted unchanged in the urine. In the present series, a study is made to evaluate the use of mannitol in cataract surgery.


 :: Material and Methods Top


Fifty patients with different types anyl grades of cataracts were studied. They were divided in two groups of 25 patients each. Group I patients were given an in­travenous infusion of 20% mannitol, 60 minutes prior to cataract operation, at a rapid rate of 60-90 drops per minute, the total dose of mannitol being 1.5-2.0 gms/ kg. body weight.

Group II served as controls in whom acetazoleamide was given in a dose of 250 mg. thrice on the previous day and 500 mg. in the morning on the day of operation. The types of cataracts in the patients is shown in [Table 1].

Intra-ocular tension was recorded by means of a "Schiotz tonometer" in each case prior to and after treatment with the diuretic agents and after this, facial and retrobulbar blocks were given by inject­ing 2% zylocaine locally. In all patients peripheral button-hole iridectomy was done and an intra-capsular cataract ex­traction was attempted with a cryo-probe. A record was made of the type of extrac­tion and the vitreous face was examined and classified into 4 categories depending on its position:

0 = normal vitreous face-concave and behind iris

+= iris bulging forwards

++= vitreous in anterior chamber

+++ = vitreous loss.


 :: Results Top


The details regarding the type of cataract extraction, pre- and post-mannitol intra-ocular tensions and position of the vitreous face are recorded and presented in [Table 2] and [Table 3].

The comparison between the average falls in the intra-ocular tensions in both the control and mannitol treated groups is shown in [Figure 1]. The position of the vitreous face as found at operation in dif­ferent individuals is shown in [Table 4].

Complications: - Mannitol-treated group I patients experienced excessive thirst, diuresis, slight headache and nau­sea, whereas control group patients had paraesthesia, epigastric burning pain, nausea, vomiting and headache. These were treated accordingly.


 :: Discussion Top


Reduction of intra-ocular pressure prior to cataract surgery is essential to keep vitreous in its "physiological posi­tion" after lens extraction and to mini­mise post-operative complications. Osmo­tic agents have been utilized to soften the eye, prior to surgery from as early as 1904 by Contonnet. [4] He used hypertonic sodium chloride for the same and since then a number of other substances like dextrose, sucrose, magnesium sulphate, sorbitol, glycerol, urea and mannitol have been used as ocular hypotensive substan­ces.

Virno and others [19] studied oral glyce­rol efficacy. in glaucoma cases and, found it most effective in reducing ocular ten­sion in cases of acute angle closure glau­coma. The ease of oral administration, lack of - toxicity, promptness and intensity of action of glycerol made them recom­mend its use prior to cataract surgery. Jaffe and Light. [11],[12] recorded 5.4 mm aver­age fall ocular tension with glycerol as compared to 0.4 mm average fall of ocular tension in control series. Though the hypotensive effect of glycerol was moderate, unpleasant. side effects like nausea and vomiting due to the bad taste of glycerol were quite frequent.

Intravenous hypertonic urea was effec­tively used by Galin et al [8],[9] and Davis et al [6] in separate studies.' Recently Crews and Davidson, [5] Tartar [18] and Scotty studied cases of acute congestive glaucoma of varied etiology with an average ocular tension of 50 mm of Hg and found 84% response with intravenous urea administration. This series also in­cluded cases with lens induced glaucoma and anterior dislocated lens with glau­coma which had not responded to therapy with acetazoleamide.

Use of hypertonic mannitol as an osmo­tic agent was reported with success by Barry et al [1],[2] in cases with functional renal failure and oliguria and has since then been an accepted part of therapy. Mannitol was also found a very effective agent for reducing cerebro-spinal fluid pressure. Wise and Charter [21] demons­trated, in anaesthetised dogs after liga­tion of renal arteries, that the cerebro­spinal fluid hypotensive effect of manni­tol was independent of its diuretic effect without secondary rebound overshoot of pressure. Effect of mannitol in reducing intra-ocular pressure was studied by Smith et al [17] in normotensive and glau­comatous eyes along with blood osmolar­ity study. and the mean: reduction in ocu­lar tension was found to be 48% in nor­motensive eyes (average fall about 8 mm . of Hg) and ,52% in glaucomatous eyes with return of intra-ocular pressure to its initial value in 2½ to 4½ hours from the time of initial reading. In vivo, this was demonstrated by Robbins and Galin, [15] to be due to temporary reduction in volume of vitreous gel following administration of hyperosmotic agents. Hyperosmotic agents produce hypertonicity of blood and cause temporary removal of fluids from vitreous gel. Brubekar and Riley [3] cal­culated the reduction of vitreous volume from changes in its weight in rabbit's eye and found it to be 2.7% with orally ad­ministered glycerine and 3.7% with in­travenously administered urea or manni­tol.

Galin and others [9] made an osmotic comparison of urea and mannitol and found urea superior as an ocular hypo­tensive agent at equal dosage levels. This was due to the lower molecular weight and poor ocular penetrance of urea. The hypotensive effect was also more lasting than mannitol, which is rapidly cleared by the kidney (1% per ml of loading dose). Also mannitol requires more ra­pid infusion time than urea. The maxi­mum reduction in intra-ocular pressure occurred approximately 45 minutes to 4½ hours following administration of either. The rise to control levels was reached in about 5 hours for urea and 3 hours for mannitol.

Weiss and Shafer [20] preferred mannitol for clinical use because of the following reasons. Urea is unstable in solution and must be freshly prepared before using­ a tedious and time-consuming procedure. It cannot be sterilized by heat. Patients complain of severe pain in the arm due to proteolytic effect of urea in 30 % solu­tion. There may be severe local reaction on extravasation with sloughing and tis­sue necrosis. Urea also had slight fibri­nolytic activity and increased bleeding tendency. Mannitol is found to be equal­ly effective and it is clinically a safe drug. Molecular weight of mannitol is three times that of urea; however, it is concen­trated in extracellular fluid compart­ments which comprises only 1/3rd of the total body water, and hence the relative disadvantage of greater molecular weight than urea is largely overcome. Weiss [21] recommended mannitol as it can be easily administered and is stable in solution, inert and non-toxic as compared to other osmotic substances.

Kornblueth et al [13],[14] used urea prior to cataract surgery in a large series, which included all types of cataract. Un­complicated and complicated cataracts ac­companied by glaucoma or high myopia were included in the study and intracap­sular cataract extraction was done with absence of vitreous loss. The results of their study of anterior vitreous face with same gradation after intracapsular cata­ract extraction with peripheral button­hole iridectomy is shown in [Table 5].

Urea was found to give best results in the above study. Keeping the same guide­lines, the present study is made in pati­ents, where mannitol was used instead of urea for obvious reasons as stated earlier.


 :: Conclusions Top


In a series of patients, it was observed that vitreous loss was absent with the use of mannitol prior to cataract surgery with reduced vitreous disturbances.

Tolerance to mannitol being generally good, except for excessive thirst and diu­resis, no unpleasant side-effects were noted. There was absence of cellulitis or tissue necrosis following accidental sub­cutaneous extravasation of mannitol.


 :: Acknowledgement Top


We take this opportunity to thank Dr. C. K. Deshpande, Dean, K.E.M. Hospital and Seth G. S. Medical College, Bom­bay-12 for allowing us to use the hospital data.

 
 :: References Top

1.Barry, K. G., Cohen, A. and LeBlanc, P.: Mannitol infusion: II. Prevention of acute 'functional renal failure during resection of aneurysm of abdominal aorta, New England, J. Med., 264: 967-970, 1961.  Back to cited text no. 1    
2.Barry, K. G., Cohen, A. and LeBlanc, P.: Mannitolization: I. Prevention and therapy of oligurea associated with cross clamping of abdominal aorta, Surgery, 50: 335-337, 1961.  Back to cited text no. 2    
3.Brubekar, R. F. and Riley, F. C.: Vit­reous body volume reduction in the rab­bit, Arch. Ophthalmol., 37: 438-442, 1972.  Back to cited text no. 3    
4.Contonnet (1904): Quoted by Duke-Elder (No. 7).   Back to cited text no. 4    
5.Crews, S. J. and Davidson, S. I.: In­travenous urea therapy in glaucoma, Brit.J. Ophthalmol., 45: 769-777, 1961.  Back to cited text no. 5    
6.Davis, M. D., Duehr, P. A. and Javid,M.: The clinical use of urea for reduction of intra-ocular pressure, Arch. Oph­thalmol., 65: 526-531, 1961.  Back to cited text no. 6    
7.Duke Elder: System of Ophthalmology ­Diseases of the lens and Vitreous: glau­coma and hypotony, Vol. XI, Henry Kimpton, London, 1969, pp. 610-612.  Back to cited text no. 7    
8.Galin, M. A., Aizawa, F. and McLeon, J. M.: Urea as an osmotic ocular hypo­tensive agent in glaucoma, Arch. Oph­thalmol. , 62: 347-352, 1959.  Back to cited text no. 8    
9.Galin, M., Davidson, R. and Pasmanik, S.: An osmotic compariscn of urea and mannitol. Amer. J. Ophthalmol., 55: 244-246, 1963.  Back to cited text no. 9    
10.Graham, P. A. and Stevens, P. R.: Sur­gical results in acute glaucoma, Brit. J. Ophthalmol. , 44: 357-262, 1960.  Back to cited text no. 10    
11.Jaffe, N. S. and Light, D. S.: Oral gly­cerine in cataract surgery, Arch. Oph­thalmol., 73: 576-578, 1965.  Back to cited text no. 11    
12.Jaffe, N. S. and Light, D. S.: Treat­ment of post-operative cataract compli­cations by osmotic agents, Arch. Oph­thalmcl., 75: 370-374, 1966.  Back to cited text no. 12    
13.Kornblueth, W. and Gombos, S.: Urea in cataract extraction, Amer. J. Ophthal­mol., 54: 753-756, 1962.  Back to cited text no. 13    
14.Kornblueth, W., Gombos, S. and Trauh. B.: The effect of osmotic agents employ­ed before cataract extraction. Amer. J_ Ophthalmol., 62: 220-224, 1966.  Back to cited text no. 14    
15.Robbins, R. and Galin, M.: Effects of osmotic agents on the vitreous body, Arch. Ophthalmol., 82: 694-699, 1969.  Back to cited text no. 15    
16.Scott, J.: The use of urea in ophthal­mology, Amer. J. Ophthalmol., 53: 988­993, 1902.  Back to cited text no. 16    
17.Smith, E. W. and Drance, S. M.: Re­duction of human intra-ocular pressure with intravenous mannitol, Arch. Oph­thalmol., 68: 734-737, 1962.  Back to cited text no. 17    
18.Tartar, R. C. and Linn, J. G.: A clini­cal study of the use of intravenous urea in glaucoma, Amer. J. Ophthalmol., 52: 323, 1961.  Back to cited text no. 18    
19.Virno, M., Contore, P., Bieth, C. and Bucci, M.: Oral glycerol in ophthalmo­logy, Amer. J. Ophthalmol., :i5: 1133­1141, 1963.  Back to cited text no. 19    
20.Weiss, D. I., Shafer, R. N. and Wise, B. L.: Mannitol infusion to reduce in­tra-ocular pressure, Arch. Ophthalmol., 65: 341-347, 1962.  Back to cited text no. 20    
21.Wise, B. L. and Chater, N.: Effects of mannitol on cerebrospinal fluid pressure, Arch. Neurol., 4: 200-201, 1961.  Back to cited text no. 21    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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