Photo Essay

Crystalline Lens Staining with Intracameral
Phenylephrine During Cataract Surgery

Michael Tsatsos, MD, PhD, FRCOphth1,2; Ioannis Athanasiadis, MD, MRCSEd(Ophth)2; Corrado Gizzi, MD, PhD2

Balal Shafi, MD2; Marilita Moschos, MD, PhD1; Anant Sharma, MD, FRCOphth2

1Aristotelian University of Thessaloniki, Thessaloniki, Greece
2Moorfields Eye Hospital, London, United Kingdom

ORCID:
Michael Tsatsos: https://orcid.org/0000-0003-1280-4113

Ioannis Athanasiadis: https://orcid.org/0000-0002-6236-7540

J Ophthalmic Vis Res 2021; 16 (1): 135–136

PRESENTATION

During intracameral use of low concentration
phenylephrine in several consecutive routine
phacoemulsification cases, we have consistently
observed a “spikes” pattern of staining in the
crystalline lens structures; however, it was
not entirely clear whether this involved just
the capsule, the cortex, or both (Figure 1).
Although it appears that the staining occurs
largely at the level of the anterior capsule,
some very faint staining could possibly be
seen on the anterior lenticular surface as well.
The formulation of intracameral phenylephrine
(Minims® Phenylephrine Hydrochloride,
Bausch & Lomb UK Ltd.) that is routinely
used in our practice consists of 0.5 ml of
10% phenylephrine preservative free minims
mixed with 0.5 ml of 2% lidocaine and 1 ml of
Balanced Salt Solution with adrenaline. This
mixture (0.2 ml) was injected in the anterior
chamber.

Correspondence to:

Ioannis Athanasiadis, MD, MRCSEd(Ophth). Moorfields
Eye Hospital at Bedford Eye Clinic, Kempston Road,
Bedford, MK42 9DJ, United Kingdom.
E-mail: athana1972@yahoo.com
Received: 18-06-2018 Accepted: 21-03-2020

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Website:
https://knepublishing.com/index.php/JOVR

DOI:
10.18502/jovr.v16i1.8261

DISCUSSION

Phenylephrine is an 𝛼-adrenergic agonist regularly
used as a dilating agent in the form of eye
drops prior to intraocular surgery such as
cataract surgery. It is also frequently used as
an intracameral injection in conditions such as
floppy iris syndrome to assist with pupillary dilation
as well as to increase the iris tone.[1, 2]

No evidence of capsular staining was observed
in our patients at postoperative visits. There
were no reported or observed cases of toxic
anterior segment syndrome or other systemic or
vision-threatening complications intraoperatively
or during the postoperative period. Although
Lockington et al reported the possibility of toxicity
associated with the presence of free radicals
in intracameral phenylephrine formulations, we
report no relevant deviations from routine practice
in our patients.[3]

Lens staining was consistent in all cases where
the intracameral phenylephrine formulation was
used. It began to appear in 20 sec, peaking at
around 1 min after the intracameral injection (Figure
2). We believe that the resulting appearance of
the crystalline lens can facilitate capsulorrhexis in
routine as well as in cases of borderline visibility

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How to cite this article: Tsatsos M, Athanasiadis I, Gizzi C, Shafi B, Moschos
M, Sharma A. Crystalline Lens Staining with Intracameral Phenylephrine
During Cataract Surgery. J Ophthalmic Vis Res 2021;16:135–135.

© 2021 TSATSOS ET AL. THIS IS AN OPEN ACCESS ARTICLE DISTRIBUTED UNDER THE CREATIVE COMMONS ATTRIBUTION LICENSE | PUBLISHED BY

KNOWLEDGE E 135

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Photo Essay; Tsatsos et al

Figure 1. Spike-like staining of the crystalline lens (arrows) following intracameral injection of phenylephrine hydrochloride.

Figure 2. Early (left) and late (right) staining of the crystalline lens following intracameral use of phenylephrine hydrochloride in
two different patients.

where usually a staining agent such as trypan
blue is considered by the surgeon. Thus, no extra
provisions need to be made resulting in reduced
cost of surgery as well as less logistical burden on
the operation theatre.

Furthering our understanding on the cause of
crystalline lens staining related to intracameral
phenylephrine and its implications will hopefully
enable us to use this agent more effectively as a
mydriatic and to facilitate capsulorrhexis in routine
as well as complicated cases.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

REFERENCES

1. Lundberg B, Behndig A. Intracameral mydriatics in
phacoemulsification cataract surgery. J Cataract Refract
Surg 2003;29:2366–2371.

2. Lorente R, de Rojas V, Vázquez de Parga P, Moreno
C, Varela J, et al. Intracameral phenylephrine 1.5% for
prophylaxis against intraoperative floppy iris syndrome:
prospective, randomized fellow eye study. Ophthalmology
2012;119:2053–2058.

3. Lockington D, Macdonald EC, Young D, Stewart P, Caslake
M, Ramaesh K. Presence of free radicals in intracameral
agents commonly used during cataract surgery. Br J
Ophthalmol 2010;94:1674–1677.

136 JOURNAL OF OPHTHALMIC AND VISION RESEARCH VOLUME 16, ISSUE 1, JANUARY-MARCH 2021