JOURNAL OF OCULAR PHARMACOLOGY AND THERAPEUTICS

Volume 18, Number 5, 2002

© Mary Ann Liebert, Inc.

Effects of Intraocular Epinephrine on the

Corneal Endothelium of Rabbits
SHIOW-WEN LIOU,1,2,3 CHENG-JEN CHIU,4 I-JONG WANG2
1 Departmentof Ophthalmology, Taipei Women’s and Children’s Hospital, Taipei, Taiwan
2 Departmentof Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
3 Taipei Medical University

4 Department of Ophthalmology, Taipei Municipal Jen-Ai Hospital, Taipei, Taiwan

ABSTRACT

Epinephrine is frequently used in the phacoemulsification to dilate pupils. To deter-

mine the effects of different concentration of epinephrine on the corneal endothelial cells,
twenty-eight rabbit eyes were equally divided into four groups. Solutions, which contained
normal saline, 1:1,000 epinephrine, 1:5,000 epinephrine and 1:10,000 epinephrine re-
spectively, were injected into the anterior chambers of the eyes of four groups of rabbits.
In vivo morphological changes of corneal endothelium and changes of thickness were
checked with specular microscopy. In vitro morphological evaluation of corneal en-
dothelium was observed in excised corneal buttons stained with alizarin red with trypan
blue, and with scanning electron microscopy. Our results showed that there was no sig-
nificant difference in cell density and corneal thickness among the four groups. Alizarin
red with trypan blue stain and SEM exam revealed smooth and distinct cell borders of
endothelial cells in each group. Intracameral injection of epinephrine does not produce
toxic effect on corneal endothelial cells in rabbits.

INTRODUCTION

Pupillary dilatation is the basic requirement to perform smooth cataract extraction. It can pre-
vent iris damage, incomplete cortex removal, posterior capsule rupture, vitreous loss and even poste-
rior lens material dislocation during phacoemulsification (phaco) and irrigation/aspiration (I/A). The
intracameral use of epinephrine, either undiluted or diluted, in the anterior chamber has been recom-
mended for the control of inadequate pupillary dilatation in routine cataract extraction or pha-
coemulsification procedures (1–3). In previous studies, we revealed that the efficacy and safety of pe-
rioperative epinephrine during phacoemulsification is promising and can be a safe adjunctive to
preoperative topical mydriatics. Intracameral infusion of 1:1,000,000 epinephrine is effective to main-
tain the pupillary size during phacoemulsification and during I/A. This concentration of epinephrine
did not affect the pulse rate nor blood pressure in patients during cataract operation (4,5).
However, there are few studies to describe the ocular safety of intraocular application of epi-
nephrine. The safety of intraocular epinephrine is important for the postoperative visual outcome, es-

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Table 1. Endothelial Cell Count (cell/mm2, Mean 6 SE) of Each Group Before and After Injection

Solution 1; 1,000 1; 5,000 1; 10,000

Timing Normal saline epinephrine epinephrine epinephrine

Pre-injection 2832 6 241 2794 6 298 2904 6 278 2698 6 254

2 hour 2911 6 264 2844 6 318 2870 6 205 2974 6 324
post-injection
1 week 2877 6 267 2743 6 269 2845 6 279 2941 6 314
post-injection
1 month 2693 6 314 2701 6 266 2683 6 264 2743 6 301
post-injection

pecially for routine cataract surgeries. The corneal endothelium is the most important cell to main-
tain corneal clarity either in normal subjects or patients receiving cataract operations. It is also a
sensitive indicator of drug toxicity for the intraocular usage. A decrease in endothelial cell density or
change in cell morphology would be expected if the solutions were toxic enough to cause cell death.
In this study, we investigated the morphological changes after application of different concentration
of epinephrine by using an animal model as previously described (6).

MATERIALS AND METHODS

Twenty-eight eyes of twenty-eight New Zealand white rabbits were equally divided into four
groups for this study. The animal protocol adhered to the ARVO Statement for the Use of Animals
in Ophthalmic and Vision Research and was approved by the IACUC of National Taiwan University
Hospital.

FIGURE 1. Alizarin red with trypan blue stain of corneal endothelia cell of the rabbits (magnifica-
tion 3 100). (A) Group 1: normal saline intracameral injection; (B) Group 2: 1:1,000 epinephrine in-
tracameral injection; (C) Group 3: 1:5,000 epinephrine intracameral injection; (D) Group 4: 1:10,000
epinephrine intracameral injection.

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 These rabbits were anesthetized with ketamine hydrochloride (50 mg/kg, Ketalar; Parke-Davis,
Morris Plains, NJ) and 2% lidocaine (20 mg/kg, Xylocaine; Astra, Astra Södertälje, Sweden). The
rabbit eyes were photographed through a specular microscope (Topcon SP2000, Topcon, Tokyo,
Japan) prior to intracameral injection. The endothelial cell count and corneal thickness were measured
using the software built in the specular microscope. Four groups of rabbit eyes were injected with
0.02 ml of normal saline, 1:1,000 epinephrine, 1:5,000 epinephrine and 1:10,000 epinephrine, into the
anterior chambers by the method described by Edelhouser et al respectively (7). The epinephrine was
purchased from commercially prepared dilutions (Bosmin Inj, Daiichi Seiyaku Co, Japan). Specular
photomicroscopy of rabbit eyes was performed again at two hours post-injection, one week and one
month later. Two rabbit eyes of each group were enucleated one month after intraocular epinephrine
injection, and the corneal buttons were cut into equal parts, of which half were stained with alizarin
red (Sigma, St. Louis, MO) and trypan blue (TCI, Tokyo, Japan) (8). The other halves of the cornea
buttons were cut into pieces about 2 3 4 mm in size; these pieces were prepared for scanning elec-
tron microscopy (6). The tissue blocks were examined and photographed under a Hitachi S570 scan-
ning electron microscope. The comparison of endothelial count is tested by Student’s t-test with one-
way ANOVA repeat measure methods and multiple comparison methods among and between each
group respectively, and p value less than 0.05 was considered statistically significant.

RESULTS

The endothelial counts of these four groups obtained from specular microscopy were compared
as in Table 1, which shows that there is no significant difference in endothelial cell density between
each group.

FIGURE 2. Scanning electron micrographs of corneal endothelial of the rabbits (magnification 3

1,000). (A) Group 1: normal saline intracameral injection; (B) Group 2: 1:1,000 epinephrine intra-
cameral injection; (C) Group 3: 1:5,000 epinephrine intracameral injection; (D) Group 4: 1:10,000
epinephrine intracameral injection.

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 The corneal thickness was also checked in all eyes by using the specular microscopy. We also
found that there is no significant difference in corneal thickness between each group.
The integrity of the endothelial sheet of the rabbit cornea was examined by Alizarin red and try-
pan blue stain and scanning electron microscopy. The morphology of all groups showed normal corneal
endothelial appearance (Figure 1 and 2). The hexagonal shape of corneal endothelium was preserved.
No abnormal endothelial cells, such as bleb formation and disintegration of cellular border, were found
in all specimens. Smooth and distinct cell borders were detected between each endothelial cell. The
thickness of intercellular border was also normal in the eyes of all groups.

DISCUSSION

The use of intracameral epinephrine in routine cataract surgery is a very promising method to
prevent miosis during surgery. However, there are few in vivo studies to verify the safety of such a
usage. Samples et al. showed that epinephrine hydrochloride, epinephrine borate and their respective
vehicles can affect the in vitro growth characteristics of human corneal keratocytes, endothelial cells
and trabecular meshwork (9). Epinephrine hydrochloride and borate at low concentrations (0.0002%)
significantly inhibited growth of both trabecular meshwork and corneal endothelial cells. Higher con-
centrations (0.02%) of these same drugs induced the same effect on the growth of keratocytes in vitro.
Hull et al. revealed that commercially available epinephrine 1:1,000 was toxic to the corneal en-
dothelium, but solutions diluted fivefold caused no endothelial damage (10).
In the present study, our results revealed that there was no significant difference in endothelial
cell density, corneal thickness or cell morphology between each group. These results implied that 0.02
ml of epinephrine (1:1,000) and diluted epinephrine (1:5,000, 1:10,000) do not damage corneal en-
dothelia of rabbits and can be safely used in routine cataract surgery without any deterious effect on
the corneal endothelium.
We reasoned that the safety of intracameral injection of epinephrine is due to the five-fold larger
volume of aqueous humor in the anterior chamber rapidly diluted the small amount of intracameral
medications as previously described (11). Additionally, there may be a wash-out effect of any toxic
solution due to aqueous humor flow at the rate of three microliters per minute. Clearance of drugs in
the anterior chamber could be rapid, and the aqueous humor might be more protective than corneal
perfusion solution. There must be a difference between the aqueous humor and the solutions normally
used for in vitro corneal perfusions; because even the best of the corneal preparations with the most
refined perfusing solutions will lead the cornea to swell in 24 hours. Therefore, our data do not show
endothelial decrease or morphological changes from any of the medications tested.
In conclusion, intracameral injection of epinephrine will not cause morphological changes in rab-
bit corneal endothelial cells. Intracameral epinephrine injection is safe during cataract operation.

Table 2. Corneal Thickness (mm, Mean 6 SE) of Each Group Before and After Injection

Solution 1; 1,000 1; 5,000 1; 10,000

Timing Normal saline epinephrine epinephrine epinephrine

Pre-injection 388 6 17 375 6 19 388 6 21 387 6 19

2 hour 386 6 18 363 6 21 386 6 17 394 6 25
post-injection
1 week 375 6 24 381 6 20 369 6 25 384 6 23
post-injection
1 month 379 6 17 378 6 24 370 6 19 384 6 24
post-injection

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Received: December 13, 2001

Accepted for Publication: April 12, 2002

Reprint Requests: Shiow-Wen Liou, M.D., Ph.D.

Department of Ophthalmology
Taipei Women’s and Children’s Hospital
12, Fu-Cho Street
Taipei, Taiwan, R.O.C.
E-Mail: swanliou0701@sinamail.com

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