Comparison of Epinephrine and Phenylephrine/Ketorolac With Regards to Pupil Size
Study Details
Study Description
Brief Summary
The objective of this study is to compare the maintenance of intraoperative mydriasis during cataract surgery between two drugs: epinephrine, which has routinely been used for decades, and Omidria, a newly FDA approved combination drug of phenylephrine and ketorolac. Patients undergoing cataract surgery that are enrolled in the trial will randomly receive one of the drugs in one eye, and the other eye will receive the drug during the subsequent cataract surgery.
Condition or Disease | Intervention/Treatment | Phase |
---|---|---|
Phase 4 |
Detailed Description
Cataract remains a leading cause of correctable blindness worldwide. Over 3.5 million cataract surgeries in the United States and 20 million cataract surgeries worldwide are performed every year. Cataract surgery is performed by making a small incision, removing the cataractous lens, most often through the process of phacoemulsification, and replacement with an intraocular lens. Like all surgeries, adequate exposure and field of view is vital for a safe and effective surgery. In cataract surgery, the field of view is limited by the diameter of the pupil. Several different drugs, such as cyclopentolate, tropicamide, phenylephrine, and epinephrine are utilized to maintain dilation (mydriasis) of the pupil during surgery.
There are currently two prospective randomized controlled trials comparing phenylephrine/ketorolac to placebo in the published literature. Both of these studies demonstrated that phenylephrine/ketorolac is superior to placebo for the maintenance of mydriasis during cataract surgery. Epinephrine has been the standard of care for intraoperative mydriasis. Phenylephrine/ketorolac (Omidria) is a newly FDA-approved additive for the maintenance of intraoperative mydriasis, but there are currently no published studies comparing epinephrine to phenylephrine/ketorolac for maintenance of mydriasis during cataract surgery.
While both of these drugs have been shown to be superior to placebo for the maintenance of mydriasis, there is a significant cost difference between epinephrine, which has been used for many years, and phenylephrine/ketorolac, which gained FDA approval in 2014. One 4 mL vial of Omidria® is utilized for one cataract surgery, which costs $465.
The primary endpoint to be measured in the study is the mean area under the curve change from baseline in pupil diameter over time to the end of cataract surgery.
Secondary endpoints will be maximum intraoperative pupil constriction, subjects with pupil diameter less than 6.5 mm at any during surgery, subjects with pupil less than 6.0 mm during cortical clean-up, and subjects with greater than 2.5 mm of pupillary constriction at any time during surgery.
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
---|---|
Active Comparator: Epinephrine Epinephrine is the intracameral additive during cataract surgery. |
Drug: Epinephrine
Epinephrine is a nonselective adrenergic agonist added to the irrigation solution during cataract surgery.
|
Active Comparator: Omidria Omidria is the intracameral additive during cataract surgery. |
Drug: Phenylephrine-ketorolac
Pehnylephrine-ketorolac is a combination of an alpha-one agonist (phenylephrine) and an NSAID (ketorolac). One 4-mL bottle of 1% phenylephrine/3% ketorolac is added to the irrigation solution during cataract surgery.
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Mean Area Under the Curve Change From Baseline in Pupil Diameter Over Time to the End of Cataract Surgery [During cataract surgery, with maximum end time of 20 minutes]
Mean area under the curve was calculated by assessing the pupil diameter at baseline and then again at 1 minute intervals until the surgery was complete (max 20 minutes). Units are in millimeters*seconds
Secondary Outcome Measures
- Maximum Intraoperative Change in Pupil Diameter [During cataract surgery, with maximum end time of 20 minutes]
This is the maximum observed change in pupil diameter, as measured compared to baseline.
- Number of Eyes With Pupil Diameter Less Than 6 mm at Any Time During Surgery [During cataract surgery, with maximum end time of 20 minutes]
Number of eyes with a measured pupil diameter less than 6 mm at any time during surgery
- Number of Eyes With Pupil Diameter Less Than 6 mm During Cortical Clean-up [During cataract surgery, cortical clean-up stage, up to 5 mins]
Number of eyes with a measured pupil diameter less than 6 mm during cortical clean-up
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Patients who are older than 18 years of age
-
Patients who are planned to undergo bilateral cataract surgery
-
Patients with baseline IOP of 5 - 22 mm Hg
-
Medicare insurance*
-
There is a significant cost difference between our two study drugs. Therefore, Medicare insurance is part of our inclusion criteria, because there is a pass-through reimbursement in place to cover the cost of phenylephrine/ketorolac. Other insurances (for example, Aetna Better Health, Highmark Freedom, Gateway) have variable or poor coverage for phenylephrine/ketorolac, which would leave the medical center responsible for the cost. Patients can never be held responsible for the cost of the medication because it is included in "covered services" for cataract surgery billing.
Exclusion Criteria:
-
Patients who are planned to undergo only unilateral cataract surgery
-
Patients who are planned to undergo cataract surgery and another surgical procedure in the same operation (eg. combined cataract and glaucoma surgery)
-
Patients with concurrent clinically significant disease, connective tissue disease, abnormal blood pressure at screening, narrow-angle or unstable glaucoma or treatment with prostaglandins, uncontrolled chronic eye disease or active corneal pathology or scarring
-
Patients with history of iritis or trauma with iris damage
-
Patients with recent eye surgery (non-laser surgery within 3 months or laser surgery within 30 days prior to study surgery)
-
Patients with clinically significant hypersensitivity to the study medications
-
Patients who have used pilocarpine (a pupil constrictor) within 6 months prior to surgery
Contacts and Locations
Locations
No locations specified.Sponsors and Collaborators
- Milton S. Hershey Medical Center
Investigators
None specified.Study Documents (Full-Text)
More Information
Publications
None provided.- 00005630
Study Results
Participant Flow
Recruitment Details | All patients who presented to one of two attending ophthalmologist's (MCC or SMP) clinics at Penn State Eye Center for cataract evaluation between November 10, 2016 and February 8, 2018 and met inclusion/exclusion criteria were invited to participate in the study. There were no incentives provided to patients for enrolling in the study. |
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Pre-assignment Detail |
Arm/Group Title | Epinephrine (1 Day), Washout (21 Days), Then Omidria (1 Day) | Omidria (1 Day), Washout (21 Days), Then Epinephrine (1 Day) |
---|---|---|
Arm/Group Description | Patients in this arm received epinephrine during the first eye surgery. Patients then waited (washout) 21 days before proceeding with second eye surgery. Patients then received Omidria during the second eye surgery. | Patients in this arm received Omidria during the first eye surgery. Patients then waited (washout) 21 days before proceeding with second eye surgery. Patients then received epinephrine during the second eye surgery. |
Period Title: Overall Study | ||
STARTED | 23 | 36 |
COMPLETED | 18 | 24 |
NOT COMPLETED | 5 | 12 |
Baseline Characteristics
Arm/Group Title | All Participants |
---|---|
Arm/Group Description | All Participants were randomized to receive all interventions. Therefore, the baseline characteristics are grouped as "all participants" |
Overall Participants | 42 |
Age (years) [Mean (Standard Deviation) ] | |
Mean (Standard Deviation) [years] |
73.1
(7.1)
|
Sex: Female, Male (Count of Participants) | |
Female |
36
85.7%
|
Male |
6
14.3%
|
Ethnicity (NIH/OMB) (Count of Participants) | |
Hispanic or Latino |
40
95.2%
|
Not Hispanic or Latino |
2
4.8%
|
Unknown or Not Reported |
0
0%
|
Region of Enrollment (participants) [Number] | |
United States |
42
100%
|
Tamsulosin Use (Count of Participants) | |
Tamsulosin |
1
2.4%
|
No Tamsulosin |
41
97.6%
|
Outcome Measures
Title | Mean Area Under the Curve Change From Baseline in Pupil Diameter Over Time to the End of Cataract Surgery |
---|---|
Description | Mean area under the curve was calculated by assessing the pupil diameter at baseline and then again at 1 minute intervals until the surgery was complete (max 20 minutes). Units are in millimeters*seconds |
Time Frame | During cataract surgery, with maximum end time of 20 minutes |
Outcome Measure Data
Analysis Population Description |
---|
Two eyes from each participant were included for all outcome measures. |
Arm/Group Title | Epinephrine | Omidria |
---|---|---|
Arm/Group Description | Epinephrine is the intracameral additive during cataract surgery. Epinephrine: Epinephrine is a nonselective adrenergic agonist added to the irrigation solution during cataract surgery. | Omidria is the intracameral additive during cataract surgery. Phenylephrine-ketorolac: Pehnylephrine-ketorolac is a combination of an alpha-one agonist (phenylephrine) and an NSAID (ketorolac). One 4-mL bottle of 1% phenylephrine/3% ketorolac is added to the irrigation solution during cataract surgery. |
Measure Participants | 42 | 42 |
Measure Eyes | 42 | 42 |
Mean (Standard Deviation) [millimeters * seconds] |
1.76
(6.51)
|
0.8
(12.01)
|
Title | Maximum Intraoperative Change in Pupil Diameter |
---|---|
Description | This is the maximum observed change in pupil diameter, as measured compared to baseline. |
Time Frame | During cataract surgery, with maximum end time of 20 minutes |
Outcome Measure Data
Analysis Population Description |
---|
Two eyes from each participant were included |
Arm/Group Title | Epinephrine | Omidria |
---|---|---|
Arm/Group Description | Epinephrine is the intracameral additive during cataract surgery. Epinephrine: Epinephrine is a nonselective adrenergic agonist added to the irrigation solution during cataract surgery. | Omidria is the intracameral additive during cataract surgery. Phenylephrine-ketorolac: Pehnylephrine-ketorolac is a combination of an alpha-one agonist (phenylephrine) and an NSAID (ketorolac). One 4-mL bottle of 1% phenylephrine/3% ketorolac is added to the irrigation solution during cataract surgery. |
Measure Participants | 42 | 42 |
Measure Eyes | 42 | 42 |
Mean (Standard Deviation) [millimeters] |
-0.71
(0.57)
|
-0.66
(0.79)
|
Title | Number of Eyes With Pupil Diameter Less Than 6 mm at Any Time During Surgery |
---|---|
Description | Number of eyes with a measured pupil diameter less than 6 mm at any time during surgery |
Time Frame | During cataract surgery, with maximum end time of 20 minutes |
Outcome Measure Data
Analysis Population Description |
---|
Each participant had two eyes included in the study |
Arm/Group Title | Epinephrine | Omidria |
---|---|---|
Arm/Group Description | Epinephrine is the intracameral additive during cataract surgery. Epinephrine: Epinephrine is a nonselective adrenergic agonist added to the irrigation solution during cataract surgery. | Omidria is the intracameral additive during cataract surgery. Phenylephrine-ketorolac: Pehnylephrine-ketorolac is a combination of an alpha-one agonist (phenylephrine) and an NSAID (ketorolac). One 4-mL bottle of 1% phenylephrine/3% ketorolac is added to the irrigation solution during cataract surgery. |
Measure Participants | 42 | 42 |
Measure Eyes | 42 | 42 |
Count of Units [Eyes] |
3
|
2
|
Title | Number of Eyes With Pupil Diameter Less Than 6 mm During Cortical Clean-up |
---|---|
Description | Number of eyes with a measured pupil diameter less than 6 mm during cortical clean-up |
Time Frame | During cataract surgery, cortical clean-up stage, up to 5 mins |
Outcome Measure Data
Analysis Population Description |
---|
Each participant had two eyes included in the study |
Arm/Group Title | Epinephrine | Omidria |
---|---|---|
Arm/Group Description | Epinephrine is the intracameral additive during cataract surgery. Epinephrine: Epinephrine is a nonselective adrenergic agonist added to the irrigation solution during cataract surgery. | Omidria is the intracameral additive during cataract surgery. Phenylephrine-ketorolac: Pehnylephrine-ketorolac is a combination of an alpha-one agonist (phenylephrine) and an NSAID (ketorolac). One 4-mL bottle of 1% phenylephrine/3% ketorolac is added to the irrigation solution during cataract surgery. |
Measure Participants | 42 | 42 |
Measure Eyes | 42 | 42 |
Count of Units [Eyes] |
3
|
2
|
Adverse Events
Time Frame | ||||
---|---|---|---|---|
Adverse Event Reporting Description | All-Cause Mortality, Serious, and Other [Not Including Serious] Adverse Events were not monitored/assessed. | |||
Arm/Group Title | Epinephrine | Omidria | ||
Arm/Group Description | Epinephrine is the intracameral additive during cataract surgery. Epinephrine: Epinephrine is a nonselective adrenergic agonist added to the irrigation solution during cataract surgery. | Omidria is the intracameral additive during cataract surgery. Phenylephrine-ketorolac: Pehnylephrine-ketorolac is a combination of an alpha-one agonist (phenylephrine) and an NSAID (ketorolac). One 4-mL bottle of 1% phenylephrine/3% ketorolac is added to the irrigation solution during cataract surgery. | ||
All Cause Mortality |
||||
Epinephrine | Omidria | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 0/0 (NaN) | 0/0 (NaN) | ||
Serious Adverse Events |
||||
Epinephrine | Omidria | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 0/0 (NaN) | 0/0 (NaN) | ||
Other (Not Including Serious) Adverse Events |
||||
Epinephrine | Omidria | |||
Affected / at Risk (%) | # Events | Affected / at Risk (%) | # Events | |
Total | 0/0 (NaN) | 0/0 (NaN) |
Limitations/Caveats
More Information
Certain Agreements
Principal Investigators are NOT employed by the organization sponsoring the study.
There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.
Results Point of Contact
Name/Title | Seth Pantanelli |
---|---|
Organization | Penn State Hershey Eye Center |
Phone | 717-531-5690 |
spantanelli@pennstatehealth.psu.edu |
- 00005630