AU681142B2 - Rapid miosis with control of intraocular pressure - Google Patents

Description

1 Description RAPID MIOSIS WITH CONTROL OF INTRAOCULAR PRESSURE Technical Field This invention relates to a miotic agent useful in post-operative cataract and intraocular lens surgery and, more particularly, to a combination of miotic agents that provides quick miosis with control of intraocular pressure 24 hours after surgery.

Backaround of the Invention Miotic agents are frequently used by ophthalmologic surgeons during intraocular surgery. The anterior chamber' is irrigated with a miotic agent after delivery of the lens in cataract surgery as well as in penetrating keratoplasty, iridectomy and other anterior segment surgery. Prompt miosis is necessary to ansure that a round pupil is obtained after cataract surgery. If any of the iris of the eye is caught in the incision or if a capsular tag is caught in the incision, the pupil will be distorted on the following day.

It is easy to miss a capsular tag in the incision since the 20 tag is clear and transparent unless one uses a miotic agent.

The other advantages obtained by the use of miotics are the facilitation of post-placed corneal scleral sutures, anterior chamber lens insertion and a decrease in postoperative peripheral anterior synechias. Many surgeons feel that miotic agents help in centering and positioning the intraocular lens implant.

Elevated intraocular pressure (IOP) can interfere with normal functioning and may result in irreversible loss of visual function. Viscoelastic agents such as Healon are often used during lens implantation which can cause elevated IOP with pressure spiking.

With the advent of modern surgical techniques and the trend to "in the bag" placement of posterior chamber IOL's, 2 more and more viscoelastic substances are being used.

Increasingly, -cataract surgery is being done on an outpatient basis, and the patient returns to the physician's office the following day. Slit lamps -and applanation tonometry are handy, and consequently most surgeons are examining their post-operative patients even better than when they were hospitalized. This has improved patient care and, on the other hand, has perhaps resulted in increased awareness of the IOP 20-24 hours after cataract surgery.

Pressure studies have shown that the IOP in the first 24 hours after cataract surgery may be very important.

Damage by raising IOP is possible to the optic nerve, the vascular supply within the eye, and the corneal endothelium Consequently, every effort should be made to 15 control the IOP from the very onset of the post-operative period.

Acetylcholine (Miochol) is the most popular miotic agent utilized by ophthalmologic surgeons. Miochol provides i" quick miosis (within minutes). However, it provides very 9**9 20 poor control of IOP after several hours, even when pressure control agents such as acetazolamide (Diamox) are utilized.

Carbachol (Miostat) does not provide as quick a miosis and is not as widely used. A miotic agent providing quick miosis with control of intraocular pressure 24 hours after surgery is needed.

Description of the Prior Art Gormaz in 1962, first reported increases in IOP in the immediate period after cataract extractions. Rich (4) in 1968 and 1969 found a significant rise in IOP was characteristic after cataract surgery. He also showed that -chymotrypsin was not required to produce this increase.

Sodium hyaluronate (Healon) has been implicated as causing a rise in IOP. Olivius and Thornburn have shown -that sodium hyalurinate induced increased IOP, arid is partially 3 reversible by removal or dilution of the viscoelastic material by irrigation Several drugs have been used to counteract the increase in IOP associated with cataract surgery. Rich in 1969 demonstrated a lowering of IOP 24 hours after surgery with the use of acetazolamide (Diamox) in high doses during the 24 hours following cataract surgery. However, acetazolamide has some undesirable side effects in some patients.

Although Timolol effectively lowered IOP after ICCE it was found to have no effect in acute post-operative pressure elevations following ECCE with IOL and the use of sodium hyaluronate Recently, a simple administration of pilocarpine gel was found to be effective in reducing IOP for the first 24 hours after ECCE with IOL (10) However, S. 15 patients frequently complained of brow ache the next day.

This same group, however, felt that there was a trend in lowering IOP post-operatively using Timolol.

Miotic agents came into use in about 1970, shortly after the onset of ECCE. In 1972, Beasley (11) found that 20 miosis was rapid with both acetylcholine 1% and Carbachol With Carbachol, miosis extended into the first postoperative day, unlike acetylcholine, where the miotic effect is gone within a very short time. However, Holland, Drance and Schulzer showed that acetylcholine 1% has a more 25 rapid onset of miosis than does Carbachol Holland, Drance and Schulzer (14) showed that acetylcholine 1%, administered intracamerally during cataract surgery, significantly reduced the IOP at 3 and 6 hours postoperatively but had no effect beyond this time. On the other hand, this same group of investigators showed that Carbachol .01% washighly effective in reducing IOP for at least 24 hours post-operatively, and in reducing the number of patients developing IOP greater than List of Cited~ References

BIBLIOGRAPHY

Patent No. 4,459,309 U.S. Patent No. 4,665,094 Gor-maz, A. Ocular Tension After Cataract Surgery.

American Journal of ophthalmology, 43:832, 1962.

Rich, Intraocular Pressures and Wound Closure After Cataract Extraction. Trans. Ophthalmol.

Soc., U.K. 88:437, 1968.

Rich, Further Studies on Early Postoperative Ocular Hypertension Following Cataract **eExtraction. Trans. Ophthalmol. Soc. U.K, 89: 639, 1969.

Olivius, and Thornburn, Intraocular Pressure After Surgery with Healon. Am. Intraocular Implant .Soc. J. 11:480, 1985.

Cher- an G. M. Rich W. J. and WrightI Raised Intraocular Pressure and other Problems with Sodium Hyaluronate and Cataract Surgery. Trans. Ophthalmol.

Soc., U.K. 103:277, 1983.

obstbaum, S.A. and Galin, The Effects of Timolol on Cataract Extraction and Intraocular Pressure. Am. J. Ophthalmol. 88:1017, 1979.

Tomoda, Tuberville, and Ward, T.O.: 25 Timolol and Postoperative Intraocular Pressure.

Am. Intraocul. Implant Soc. LT. 10:180, 1984.

Ruiz, Wilson, Musgrove, K.H. and Prager, anageMent of Increased Intraocular Pressure After Cataract Extraction. Am. LT. Ophthalmol., 103:487, 1987.

(11) Beasley, Mlotics In Cataract Surciery. Arch.

Ophthalmol., 88:49, 1972.

(12) Douglas, A -comparison of Acetylcholinl and Carbachol Followinar Cataract Extraction. Can. Jr.

Ophthalmol., 8:75, 1973.

(13) Hollands, Drance, and Schulzer, The Effect of Intracamerol Carbachol on Intraocular Pressure After Cataract Extraction. Am. J. Ophthalmol,, 104:225, 1987.

(14) Hollands, Drance, and Schulzer, The Effect of Acetylcholine on Early Postoperative Intraocular Pressure. Am. J. Ophthalmol., 103:749, 1987.

Hayrch, Anterior Ischemic Optic Neuropathy, IV, Occurrence After Cataract Extraction. Arch. Ophthalmol., 98:1410, 1980.

Statement Of The Invention According to the first embodiment of the invention there is provided a method of inducing quick miosis while controlling intraocular pressure in a mammal during ocular surgery comprising the steps of: injecting into the anterior chamber of the eye of the mammal a first miotic agent selected from components of the formula: X" H H 0 SI 1 II

(R

2 3

-N-C-C-O-C-R

1 SH H where R and R 1 are lower alkyl groups containing 1 to 5 carbon atoms and X- is an anion; and :i injecting into the anterior chamber of the eye a second miotic agent selected from components of the formula: X' H

O

I II

(R

2 3 -N -C-C-0-C--(CH 2 )n-NH 2

HH

20 whre R 2 is a low alkyl group of 1-5 carbon atoms, n is an integer from 0-3 and X is an anion.

This invention is directed to an improvement in or modification of the invention described and claimed in Australian Patent No. 642191.

An improved miotic agent is provided that provides rapid miosis with 24 hour control of intraocular pressure. This miotic agent reduces or eliminates the need for IOP control agents such as Diamox and reduces IOP after use of viscoelastic agents such as Healon.

The miotic agent described herein resides in the combined use of an acetylcholine type of agent with a carbachol type of agent. The combination provides fast onset of miosis, a prolonged miotic effect, and long-term control of IOP for 24 hours. The IOP is maintained at or below 25 mmHg with very few, if any, pressure spikes in the 24 hour, post-operative period.

The miotic agent described herein is convenient to use, The agent is safe and effective since it is a combination of two agents approved for use in the same procedure.

[G;\WPUSCR\LIBFF100003;ER ~11111~ The miotic agent described herein will find general use in intraocular surgery and is especially useful in the class of patients who enter the procedure with elevated intraocular pressure, such as glaucoma patients. It will also prove very useful in procedures in which Healon is used to aid in the insertion of an intraocular lens.

The acetylcholine and carbachol materials can be used sequentially or simultaneously. Also described herein is the aspect of packaging the two agents in a common container having two separate compartments. The agents are combined and dissolved in a common carrier immediately before use.

These and many other features and attendant advantages of the invention will become apparent as the invention becomes better understood by reference to the following detailed description when considered in conjunction with the accompanying drawings.

Brief Description of the Drawings Figure la is an enlarged view of a package containing the component of the miotic agent described herein; 15 Figure lb is a view taken along line lb-lb of Fig. la; Figure lc is a view similar to Fig. lb but showing unit dosage and aqueous solution mixed and ready to be withdrawn by a hypodermic needle.

Figure 2 is a set of curves showing pre-operative and post-operative intraocular pressure IOP in a group of patients receiving Miochol with Diamox; S 20 Figure 3 is a set of curves showing pre-operative and post-operative intraocular pressure IOP in a group of patients receiving Miochol without Diamox; Figure 4 is a set of curves showing pre-operative and post-operative intraocular pressure IOP in a group of patients receiving Miostat with Diamox; Figure 5 is a set of curves showing pre-operative and post-operative intraocular pressure IOP in a group of patient receiving Miostat without Diamox; Figure 6 is a set of curves showing pre-operative and post-operative intraocular pressure IOP in a group of glaucoma patients receiving Miochol; Figure 7 is a set of curves showing pre-operative and post-operative intraocular pressure IOP in a group of glaucoma patients receiving Miostat; and Figure 8 is a series of bar graphs illustrating the pre- and post-operative IOP in 18 patients administered the combined miotic agent of the invention, Detailed Description of the Invention The first active agent in the miotic composition described herein is a compound of the formula: X" H H 0 I I H H where R and R t are lower alkyl groups containing 1 to 5 carbon atoms and X- is an anion such as halo.

IG WPUSER\LIBFFl00003.:E r The preferred member of this group is acetylcholine where R and R 1 are all methyl and X- is chloro. Acetylcholine is a parasympathemetic agent. It is utilized in concentrations from 0.1 to 5% usually at 1 by weight. Acetylcholine is unstable so it is provided in dry powder form and is mixed with physiological', -rt, liquid carrier before 3 use. The dry material can be mixed with an inert lyophizing .erial such as mannitol in ratios of 1/1 to 10/1, usually 3/1 by weight. The reconsti .1 aqueous solution contains 1% acetylcholine and 3 mannitol by weight. The usual dose for administration is about 2 ml.

The second active material in the miotic composition is a compound of the formula: X' H H 0 I I II (R2)3-N-C-C--O-C--(CH)n-NH 2 I I H H where R 2 is a low alkyl group of 1-5 carbon atoms, n is an integer from 0-3 and X is an S anion such as halo. The preferred material carbachol, is a compound in which n is 0, R 2 are all methyl and X is chloro. Carbachol is provided as a sterile aqueous salt solution in a concentration from 0,001 to 1.0 percent by weight, usually at about 0.01% by weight.

The isotonic salt carrier includes the following inactive salts: Salt by Weight NaCI 0,64 KCI 0.075 CaCI HzO 0.048 MgCl 2 6H20 0.03 *Sodium acetate 3H20 0.39 Sodium citrate 21-120 0.17 The pH is adjusted to neutral with sodium hydroxide or hydrochloric acid as needed, Referring now to Figure 1, the two agents can be provided in a two compartment package 10, The package is in the form of a uni-vial 12 having a first compartment 14 sealed by a first elastomer plug 16 and a second compartment 17 sealed by a second elastomer plunger-stopper 18. The first compartment 14 contains a unit dosage or charge of the first agent such as acetylcholine and the lyophizing agent such a mannitol and the second compartment 17 contains an aqueous solution 22 of the second agent in a solution of salt in isotonic proportions and concentrations, The plunger-stopper 16 is pressed downwardly which forces the plug 18 into the lower compartment. The plungerstopper 16 comes to rest on the shoulder 25 formed along the rim 27 of the annular section 31 of the uni-vial 10. The solution 22 falls into the first compartment 14 and dissolves the dry charge 20. In use, a hypodermic needle, not shown, is inserted through the plunger-stopper 16 into the second compartment 17 to withdraw the solution. After the dry mixture of compounds is dissolved, the combined miotic agent is withdrawn into ao the syringe and is ready for use.

IG0 WPUSEAL1IBFFI00003:ER Studies were conducted using Miochol (Acetylcholine) and Miostat sequentially, and combined separately during intraocular surgical procedures.

The miotic agent described herein can be used as follows. After extraction of a cataract, the-capsule is retained. It has an anterior flap. To facilitate insertion of the lens, the capsule is inflated and Healon is applied.

After insertion of the lens in the capsule, the Miochol .agent is injected. As the pupil is constricting, closure of the wound takes place. The viscoelastic agent is removed from the capsule coating by aspiration with saline. The Miostat solution is then added to the anterior chamber. As the last stitching of the incision is completed, the iris is examined for roundness and for inclusion of iris or capsular 15 tags in the incision.

When the combination of acetylcholine and carbachol is utilized in a common carrier, a portion of the combination solution is added after lens insertion and closure of the wound takes place. The viscoelastic agent is aspirated from the anterior chamber and the combination miotic agent is S added again as the stitching of the wound is completed.

The following studies provide indications of the ability of the combination miotic agent of the invention to provide long-term IOP control without the use of Diamox and 25 excellent control of glaucoma patients undergoing ECCE.

The average intraocular dose of Miochol is 0.5 to 2 ml of the 1% solution and of the Carbachol during surgery is to 2 ml of a 0.01% solution.

The intraocular pressure was measured with the Goldman applanation tonometer the day before surgery during the preoperative visit. The second intraocular pressure measurement was tak(e 20-24 hours after surgery at the first post-operative visi' a 0 SURGICAL TECHNIQUE 1. Standard ECCE with intraocular lens implantation (either PMMA with Prolene loops, or all PMMA) was performed.

All phakoemulsification with intraocular lens implantation patients were excluded. All known glaucoma patients were also excluded from this part of the study.

2. Methods and procedures: Honan cuff. 15-30 minutes pre-operatively, approximately 11 mm incision, manual extracapsular cataract extraction (pressure below, counter-pressure above), Healon (sodium hyaluronate) was used in all cases, machine cortical irrigation and aspiration containing Epinephrine with either Site unit or Series 10,000 Coopervision unit, "in the bag" placement of the posterior chamber intraocular lens, 15 machine irrigation and aspiration of Healon, Miotic agent instilled into the anterior chamber and the chamber was aspirated to remove the Healon, closure with interrupted 10-0 nylon sutures.

Injectable medication used at surgery were Garamycin (1/2 to 1 cc), and Celestone (1/2 to 1 cc).

3. Topical medications used upon completion of surgery were Tobrex, Maxidex, and Betoptic. Celestone, Maxidex and Betoptic are underlined because they are known to affect intraocular pressure.

ECCE surgery has been conducted utilizing acetylcholine and carbachol sequentially and combined on two sets of patients. All surgeries were successful with quick miosis followed by rapid lowering of IOP and low IoP after 24 hours.

The following table and Figure 8 show the lOP of 9 patients administered the two miotic agents sequentially.

Quick miosis was observed. The Post-Op IOP (24 hours after surgery) was the same or lower than the Pre-Op pressure.

Pa tienrt post-On DPIta IOP 19 18 21 16 19 18 0 0000..

0* 0 00..

0 The combined iniotic agent of the invention was administered to 18 additional subj3ects. Measurements of IOP were taken on the operated eye (OP) and the fellow (EEL) eye before the operation at surgery (PRE) and 24 hours after the operation (POST) The pupil size was measured at (AT) and 24 hours after surgery (POST) The following Table shiows thie measurements, the differences (DELTA) and the maximum, *minimum and averages of the measurements.

Pupil Pupil De I t *~r.PzL9. PALQ Q5~~1 AT, I-k$T PP 0..0 ease a 00*0 4. 5 6 4 3 3 3.

2.5 0.02 2 4 25 2 3 2 2 2 2. 194 0.572

I

2 -15

I

0 0 -12 -13 2 0 -3 4 5.9902 -3 -3 0 0 -3 -3 -0722 0 44 ln x.

Min.

Ave.

STD

22 13 17.278 2 .46138 23 14 17.5556 2. 47867 ~15 4 1.4 9 4 5.8054 26 16.a333 4.25994 The 'Post-Op IOP is lower than the Pre-Op 10OP showing good control. The pupil is still constricted 24 hKoiUrs later.

1 1 A retrospective, clinical study was conducted on preoperative and, post-operative intraocular pressures of patients administered Acetylcholine or Carbachol while undergoing extracapsular, cataract extraction with intraocular lens implantation. The surgery was performed in a similar fashion by one surgeon (the author). Intraocular pressure was measured with the Goldman applanation tonometer the day before surgery during the pre-operative visit. The second intraocular pressure measurement was taken by Goldman applanation tonometer 20-24 hours following surgery at the first post-operative visit.

In the early stages of this retrospective study, it became apparent that post-operative pressure spikes fee*** occurring 20-24 hours later were of a major concern. This S 15 retrospective study compares the post-operative intraocular pe" pressure (IOP) in 4 groups following standard extracapsular cataract extraction with intraocular lens (ECCE with IOL) The 4 groups consisted of Miochol (acetylcholine chloride) alone, Miochol with 500mg. Diamox (acetazolamide) given a a orally at 1800 hours, Miostat (Carbachol) with 500mg. Diamox given orally at 1800 hours, and fourthly, Miostat alone.

Figures 2 and 3 show the spiking behavior of the group of patients treated with Miochol with or without Diamox.

Figures 4 and 5 show that the patients treated with Miostat 25 with or without Diamox had good control of 'lOP.

Surprisingly, the group not receiving Diamox had better control.

The patients given Miochol only had an average preoperative intraocular pressure of 14.2 and an average postoperative pressure of 26.5. However, 4 of these 11 patients had pressure spikes of over 30, and 1 of 44mmHg. The average increase in intraocular pressure was 12.3mmHG.

patients were given Miochol at the time of surgery with 500mg. of Diamox orally at 1800 hours on the day of surgery,, in an attempt to reduce prestUre spikes. The 12 average post-operative pressure was 20.1 with an average increase of 6.RmmHg. of pressure. However, in this group, there were 9 of 35 patients with intraocular pressure of above 25 to a high as 42.

38 patients were given Miostat at the time of surgery with Diamox 500mg. at 1800 hours the day of surgery. The average post-operative intraocular pressure was 16.9, and the average increase in intraocular pressure was 2.3mm.

Only 3 of 38 patients had pressures over 25, the highest being 29. This appeared to be an improvement in control of intraocular pressure 20-24 hours later over both groups of patients using Miochol.

36 patients received only Miostat at surgery with no Diamox given the day of surgery. The average post-operative intraocular pressure was reduced 0.8mm. Only 1 of 36 patients had a post-operative intraocular pressure of over This group appeared to be clinically at least as well controlled as the Miostat with Diamox group, and certainly superiorly controlled to the Miochol group.

S 20 During this retrospective study, 16 known cases of glaucoma were uncovered an admittedly small group. All glaucoma cases were on medication and felt to be controlled, o although 2 patients, 1 in each group, did have a preoperative pressure of 25. 8 of these patients had been 25 given Miochol at surgery, and 8 had been given Miostat. All of these patients received Diamox 500mg. at 1800 hours the day of surgery. The surgical technique was the same except a full iridectomy was performed when indicted. (b) Injectable medications at the time of surgery were Garamycin and Celestone. Topical medications used upon completion at surgery were Tobrex, Maxidex, and Betoptic. 500mg. of Diamox was used orally at 1800 hours the day of surgery in all cases.

Figure 6 shows the data for the 8 patients who had been given Miochol at surgery. The average pre-operative 13 intraocular pressure was 21, and the average post-operative Intraocular pressure was 37, an increase of 16.3mm. 7 of the 8 patients had intraocular pressures of 30 or over, one patient's pressure spiked to 54mm.

Figure 7 shows the data for the 8 patients who had been given Miostat at surgery. Average pre-operative' intraocular pressure was 17, and the average post-operative intraocular pressure was the same. Only 2 patients had intraocular pressures above 21, one patient of 26 and one patient-of 28.

A comparison of the post-operative intraocular pressures in the glaucoma population indicates that there was significant spiking of intraocular pressure 20-24 hours later in the Miochol group compared to the Miostat group of patients.

This retrospective, clinical study of the use of 15 standard ECCE supports the safety and efficacy of the combined miotic agent of the invention. The miotic agent containing both Miochol and Miostat (carbachol appears to be a superior pharmacological agent to one cont'ining Miochol (acetylcholine chloride in controlling IOP 20-24 20 hours later, as measured by applanation tonometry. In the routine care of standard ECCE with IOL, Diamox 500mg. orally at 1800 hours does not seem necessary, if using the miotic agent of the invention containing both Miochol and Miostat.

In glaucoma cases, the miotic agent of the invention should 25 be effective in providing quick miosis while controlling

C..

post-operative IOP 20-24 hsurs later.

It is to be realized that only preferred embodiments of the invention have been described and that numerous substitutions, modifications and alterations are permissible without departing from the spirit and scope of the invention as defined in the following claims.

Claims (16)

1. A method of inducing quick miosis while controlling intraocular pressure in a mammal during ocular surgery comprising the steps of: injecting into the anterior chamber of the eye of the mammal a first miotic agent selected from components of the formula: X- H H 0 I I II (R)3-N-CC---O-C-R1 I I H H where R and R 1 are lower alkyl groups containing 1 to 5 carbon atoms and X- is an anion; and injecting into the anterior chamber of the eye a second miotic agent selected from 10 occ nponents of the formula: SX- H H O (R2),-N-C-C-O-C-(CH 2 n -NH 2 IH H where R 2 is a low alkyl group of 1-5 carbon atoms, n is an integer from 0-3 and X is an anion.

2. A method according to Claim 1 in which the X- is halo. 15 3. A method according to Claim 2 in which R and R 1 are methyl and X- is chloro.

4. A method according to Claim 3 in which R 2 is methyl, n is O and X- is chloro.

5. A method according to any one of Claims 1 to 4 in which the two agents are injected to the eye sequentially.

6. A method according to any one of Claims 1 to 4 in which the first agent is injected 20 into the eye before the second agent.

7. A method according to any one of Claims 1 to 4 in which the two agents are injected into the eye simultaneously.

8. A method according to Claim 4 in which the first agent is dissolved in a pharmacologically acceptable aqueous carrier in a concentration from 0.1 to 5% by weight.

9. A method according to Claim 8 in which the solution of first agent further includes a lyophizing material in a weight ratio to agent of 1/1 to 10/1. A method according to Claim 9 in which the lyophizing material is mannitol present in an amount of about 3 by weight,

11. A method according to Claim 8 in which the second agent is dissolved in a pharmacologically acceptable isotonic aqueous saline in an aniount from 0.001 to percent by weight. IG:\WPUSER\LIBFFIo00003ER

12. A method according to Claim 11 in which the second agent is present in the saline solution in an amount of about 0.01% by weight.

13. A method according to Claim 12 in which both miotic agents are dissolved in the pharm.acologically acceptable aqueous saline as a common carrier.

14. A method according to Claim 13 in which before injecting the agents, the first agent is a dry powder and mannitol is a dry powder in unit dosage form are disposed in a sterile, closed package and the second agent dissolved in said saline in unit dosage is disposed in a second sterile package and further including the steps of: combining the contents of the two package to form a solution of the two agents in o1 said saline and then injecting said solution into the eye of said mammal. A method according to any one of Claims 1 to 14 in which the mammal is a human.

16. A method according to Claim 15 in which the human subject is undergoing s extracapsular cataract extraction with intraocular lens implant surgery.

17. A method according to Claim 16 in which the human subject is suffering from 15 glaucoma. S 18. A unit dosage package of a combination miotic capable of quick miosis while controlling intraocular pressure, when used in a method of any one of claims 1 to 17, which unit dosage package comprises: a first sterile container containing a unit dosage of said first miotic agent in dry 20 powder form and; a second sterile container containing unit dosage of a solution of said second miotic agent in an aqueous saline which is a solvent for the first miotic agent.

19. A package according to Claim 18 in which the containers are physically joined.

20. A package according to Claim 18 in which the containers are joined by an elastomer seal penetrable by a hypodermic needle, Dated 30 June 1994 James W. McKinzie Patent Attorneys for the Applicant/Nominated Person SPRUSON FERGUSON IGAWPUSER\LiFF0003.ER I_ ABSTRACT Rapid Miosis With Control Of Intraocular Pressure Quick miosis with 24 hour control of intraocular pressure of patients undergoing extracapsular cataract extraction surgery is achieved by injecting into the eyes of the patient during surgery acetylocholine as a first miotic agent and carbachol as a second miotic agent. Acetylcholine provides quick miosis while carbachol enhances the miotic effect while providing post-surgery control of intraocular pressure. The two miotic agents can be dissolved in a common saline carrier. The two agents can be combined in a unit dosage package (10) by disposing acetylcholine in powder form (20) in a first compartment (14) and a solution (22) of carbachol in a second compartment The combined miotic agent of the invention is especially useful when substances which raise IOP such as viscoelastic agents are used during ocular surgery and/or with sensitive patients who enter the surgery with elevated pressure such as those suffering from glaucoma. F* Fig, Ib. S itO I[N\LIBMI0141:.R