Clinical Ophthalmology Dovepress

open access to scientific and medical research

Open Access Full Text Article o R i g i n al r e s e arc h

Effect of heparin in the intraocular irrigating

solution on postoperative inflammation
in the pediatric cataract surgery
This article was published in the following Dove Press journal:
Clinical Ophthalmology
16 June 2009
Number of times this article has been viewed

Yelda B Özkurt Purpose: To evaluate the influence of irrigation of the anterior chamber with heparin sodium
Arzu Taşkıran on postoperative inflammation after pediatric cataract surgery.
Nadire Erdogan Setting: Kartal Training and Research Hospital, First Eye Clinic, Istanbul, Turkey.
Baran Kandemir Design: Randomized prospective double-blind study.
Ömer K Doğan Methods: Fourteen consecutive eyes from 14 patients aged 8.9 ± 5.9 years, (range 3–18 years)
(group 1) and 19 eyes from 19 patients aged 9.1 ± 5.2 (range 1.5–18 years) (group 2) underwent
Department of Ophthalmology, Kartal
pediatric cataract surgery. Five patients in group 1 were between three and five years old.
Training and Research Hospital,
Istanbul, Turkey One patient was 1.5 years old and six patients in group 2 were between three and five years
old. During the procedure, group 1 received anterior chamber irrigation with heparin sodium
(5 IU/cc) and 1 ml of heparin sodium (concentration 10 IU/ml) added to the irrigating balanced
salt solution (BSS Plus; Alcon Laboratories, Inc., Fort Worth, TX, USA) while group 2 received
BSS without heparin sodium only. Cases aged under three years received anterior vitrectomy
in addition to posterior capsulorrhexis. One eye received anterior vitrectomy in group 1 and
two eyes received anterior vitrectomy in group 2. Cases with preoperative complications were
not included in the study. Early and late postoperative inflammatory complications, including
fibrin formation, anterior and posterior synechia, cyclitic and pupillary membrane formation
were recorded and compared.
Results: Mild anterior chamber reaction was observed in three patients in Group 1, while
nine cases in group 2 experienced marked anterior chamber reaction. In four of nine patients
from group 2, anterior chamber reaction was severe and resulted in pupillary membrane and
synechia despite treatment in the postoperative 7th day, while in all three cases in group 1,
reaction disappeared by the 7th day.
Conclusion: Anterior chamber irrigation with heparin during pediatric cataract surgery may
minimize early inflammatory reaction and decrease the number of postoperative inflammatory
related complications.
Keywords: pediatric, cataract, surgery, inflammation

Pediatric cataract surgery may result in preoperative and postoperative complications.1

Cataract surgery and other intraocular procedures have a higher incidence and more
pronounced postoperative inflammatory reactions in children compared with adults.1
These reactions are associated with younger age and may be affected by surgical technique,
Correspondence:  Yelda Özkurt
Korkut sokak, Dumankaya evleri, A1B intraoperative injury to adjacent structures such as iris, presence of antecedent ocular
blok, Şen apartmanı, 9/7, Kozyatağ, infection, and remnants of retained cortical material.1 Heparin has anti-inflammatory and
Istanbul, Turkey
Tel +90 216 4164352
antiproliferative effects in addition to its anticoagulant function,2 inhibits fibrin formation
Email yeldaozkurt@yahoo.com after intraocular surgery, and has also been shown to inhibit fibroblast activity.3

submit your manuscript | www.dovepress.com Clinical Ophthalmology 2009:3 363–365 363

Dovepress © 2009 Özkurt et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article
which permits unrestricted noncommercial use, provided the original work is properly cited.
Özkurt et al Dovepress

In this prospective study, we evaluated the influence of (average 9.4 months = ±7.15). The Fisher’s exact test was
anterior chamber irrigation with heparin sodium on early used for statistical analysis.
postoperative inflammation and cellular reaction after pedi-
atric cataract surgery. Results
The two groups were comparable in age and distribution of
Patients and methods sex (Student t-test p  0.05). There were no statistically signi­
Fourteen eyes from 14 pediatric cataract cases aged 8.9 ± ficant differences between the two groups. Table 1 shows
5.9 years (group 1: range 3–18 years) received anterior chamber preoperative and postoperative patient data in groups 1 and 2.
irrigation with heparin sodium (5 IU/cc) during operation and Mild anterior chamber reaction was observed in only three
received 1 ml of heparin sodium (concentration 10 IU/ml) patients in group 1, while nine cases of group 2 experienced
added to the irrigating solution of BSS (BSS Plus) whilst in marked anterior chamber reaction. In four of nine patients
19 eyes from 19 pediatric cataract cases aged 9.1 ± 5.2 (group 2: from group 2, anterior chamber reaction was severe which
range 1.5–18 years), BSS without heparin sodium was used. resulted in pupillary membrane and synechia, despite treat-
All patients had no ocular pathology other than cataract. ment on the postoperative 7th day (Table 2).
The parents were asked to sign an informed consent for the pro- In two of these four cases, synechiatomy was performed
cedure. All children underwent cataract extraction under gen- as a second surgical procedure. In the long-term follow up in
eral anesthesia by two experienced surgeons. After a 3.2-mm two cases from group 2, pupillary irregularity was reported.
limbal tunnel incision was created, the anterior chamber was It was seen that anterior chamber reaction disappeared in all
entered, and a continuous curvilinear capsulorrhexis (CCC) three cases of group 1 on the 7th day and pupillary irregu-
was made with the Utrata forceps. The size of anterior capsu- larity was not reported in any of these cases. Hyphema or
lorrhexis was between 5.0 mm and 5.5 mm. After the nucleus intraocular hemorrhage due to heparin were not reported in
was hydrodissected, lens material was aspirated using the any cases in both groups. Differences found between the
automated irrigation/aspiration mode of the phacoemulsi- group 1 and the group 2 could have occurred by chance or
fier after the hydrodissection. All cases received posterior because of the small size of the studied population.
capsulorrhexis with a diameter of 3.5 mm and 4.0 mm. One eye
received anterior vitrectomy in group 1 and two eyes received
Discussion
The pathogenesis of postoperative fibrinoid inflammation is
anterior vitrectomy in group 2. Cases aged under three years
unknown. Any defect in the blood–aqueous barrier (BAB),
received anterior vitrectomy in addition to posterior capsulor-
possibly due to intraocular inflammation, preoperative high
rhexis. One eye received anterior vitrectomy in group 1 and
intraocular pressure (IOP), or excessive eye manipulation
two eyes received anterior vitrectomy in group 2.
during surgery may lead to a disturbance in the coagulation
All eyes having intraocular lens (IOL) implantation
and fibrinolytic pathway.4
received monoblock, hydrofobic foldable acrylic IOL
A tendency towards increased postoperative inflammation
(AcrySof MA30BA; Alcon Laboratories, Inc.). Cases with
in children is well recognized.5 Intraocular inflammation mani-
peroperative complications were not included in the study.
fests itself as increased cells and flare, inflammatory precipi-
No oral or subconjunctival steroids were used. Standardized
tates on the IOL and the endothelium, formation of synechia,
postoperative treatment comprised prednisolone acetate 1%
and inflammatory cyclitic membranes.1 The fibrinoid reaction
(Pred Forte®; Allergan, Inc., Irvine, CA, USA) eight times
after pediatric cataract surgery is caused by the breakdown
a day for one week followed by six times a day for the
of the immature BAB and insufficient trabecular meshwork
second week and tapered over six weeks, and ciprofloxacin
0.3% (Ciloxan; Alcon Laboratories, Inc.) and and ketorolac
0.5% three times a day for one month. All patients were Table 1 Postoperative complications after cataract surgery
followed daily for the first three days, once a week for the Characteristics Group 1 Group 2 Statistical
(14 eyes) (19 eyes) difference
first month, and at the 3rd and 6th months. At all visits,
postoperative intraocular complications, including fibrin Gender (M:F) 6:8 9:10 P = 1.0000

formation, anterior and posterior synechia, cyclitic and Cells in anterior chamber 10 3 9 P = 0.1604

pupillary membrane formation, and posterior capsular opaci- Fibrin in anterior chamber 0 4 P = 0.1192

fication (PCO) were recorded and compared. The follow- Pupillary membrane and anterior 0 4 P = 0.1192
synechiae
up period after surgery was between three and 24 months

364 submit your manuscript | www.dovepress.com Clinical Ophthalmology 2009:3

Dovepress
Dovepress Irrigating solution and postoperative inflammation

Table 2 Posterior capsular opacification and its additive effect to prevent PCO in children. In our
Group 1 Group 2 Statistical study, in the 6th month, PCO was reported in only one case
(n = 14) (n = 19) difference
from group 1 and in four cases from group 4.
1st week 0 0
Hyphema, which can be seen during surgery due to
1st month 0 1 P = 1.0000
heparin irrigation, was not seen in our study. However, this
3rd month 1 2 P = 1.0000
risk can also be diminished by using low molecular weight
6th month 1 4 P = 0.3662 heparin.8 Iverson and colleagues suggest that fragmin, at a
concentration of 5 IU/mL, lowers the risk of hemorrhage
during vitreoretinal and lensectomy surgeries.10.
fibrinolytic activity.6 Secondary complications of severe
Our results suggest that adding heparin sodium to the
fibrinoid reaction include papillary membrane and opacifica-
irrigating solution seems to be a safe, effective, and prom-
tion of the anterior hyaloid face.6 Therefore, measures that may
ising method to prevent early postoperative inflammatory
prevent or decrease inflammation in these eyes deserve consid-
reactions and PCO formation in the long term after pediatric
eration.7 In addition to its well-known anticoagulant activity,
cataract surgery.
heparin has anti-inflammatory and antiproliferative properties.6
Heparin inhibits fibrin formation after intraocular surgery and
has also been shown to inhibit fibroblast activity.3
Disclosure
The authors report no conflicts of interest in this work.
Due to its antithrombin effect, heparin inhibits fibrin forma­
tion by accelerating the control mechanisms for thrombin and
activated X-factor.8
References
1. Rumelt S, Stolovich C, Segal ZI, Rehany U. Intraoperative enoxaparin
Previous studies elucidate several mechanisms through minimizes inflammatory reaction after pediatric cataract sutgery. Am J
Ophthalmol. 2006;141:433–437.
which heparin may inhibit inflammation including induction of
2. Kruger A, Amon M, Formanek CA, Schild G, Kolodjaschna J,
apoptosis in human peripheral blood neutrophils, inhibition of Schauersberger J. Effect of heparin in the irrigation solution on post-
the complement activation and lymphocyte migration, l- and operative inflammation and cellular reaction on the intraocular lens
surface. J Cataract Refract Surg. 2002;28:87–92.
p-selectin, adhesion-molecule support of the initial attachment 3. Dada T. Intracameral heparin in pediatric cataract surgery. J Cataract
of leukocytes to the vessel wall at the inflammation sie, neutro- Refract Surg. 2003;29:1056.
4. Mehta JS, Adams GG. r-TPA following pediatric cataract surgery.
phil chemotaxis, and generation of refractive oxygen species by
Br J Ophthalmol. 2000;84:983–986.
mononuclear and polymorphonuclear leukocytes.1,4,6 Another 5. Basti S, Aasuri M, Reddy MK, Preetam P, Reddy S, Gupta S,
useful adjunct for the prevention of membrane formation over Naduvilath T. Heparin-surface-modified intraocular lenses in paediatric
cataract surgery: prospective randomized study. J Cataract Refract
the IOL optic is the use of a heparin-coated IOL. Surg. 1999;25:782–787.
In our study of pediatric cataract surgery, addition of 6. Bayramlar H, Totan Y, Borazan M. Heparin in the intraocular irrigating
solution in pediatric cataract surgery. J Cataract Refract Surg.
heparin to the irrigating BSS prevented postoperative inflam-
2004;30:2163–2169.
matory complications. In this study it was shown that in 7. Wilson ME, Trivedi RH. Low molecular-weight heparin in the
heparin sodium-added group 1 patients, early postoperative intraocular irrigating solution in pediatric cataract and intraocular lens
surgery. Am J Opthalmol. 2006;141:537–538.
inflammatory reactions were rare. Bayramlar and colleagues6 8. Johnson RN, Blankenship G. A prospective, randomized clinical trial
concluded that the addition of heparin to the irrigating solu- of heparin therapy for postoperative intraocular fibrin. Ophthalmology.
1988;95:312–317.
tion during surgery decreases postoperative fibrinoid reaction
9. Knight-Nanan D, O’Keefe M , Bowell R. Outcome and complications
and late inflammatory complications. of intraocular lenses in children with cataract. J Cataract Refract Surg.
The incidence of PCO after pediatric cataract surgery has 1996;22:730–736.
10. Iverson D, Katsura H, Hartzer MK, et al. Inhibition of intraocular fibrin
been reported as high as 95.8%.9 Several studies demonstrated formation following infusion of low-molecular-weight heparin during
the antiproliferative effect of heparin on lens epithelial cells vitrectomy. Arch Ophthalmol. 1991;104:405–409.

Clinical Ophthalmology Dovepress

Publish your work in this journal
Clinical Ophthalmology is an international, peer-reviewed journal PubMed Central and CAS, and is the official journal of The Society of
covering all subspecialties within ophthalmology. Key topics include: Clinical Ophthalmology (SCO). The manuscript management system
Optometry; Visual science; Pharmacology and drug therapy in eye is completely online and includes a very quick and fair peer-review
diseases; Basic Sciences; Primary and Secondary eye care; Patient system, which is all easy to use. Visit http://www.dovepress.com/
Safety and Quality of Care Improvements. This journal is indexed on testimonials.php to read real quotes from published authors.
Submit your manuscript here: http://www.dovepress.com/clinical-ophthalmology-journal

Clinical Ophthalmology 2009:3 submit your manuscript | www.dovepress.com

365
Dovepress