CA2034128C - Rapid miosis with control of intraocular pressure - Google Patents

Abstract

Quick miosis with 24 hour control of intraocular pressure of patients undergoing extracapsular cataract extraction surgery is achieved by applying to the eyes of the patient during surgery acetylcholine 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 by disposing acetylcholine in powder form in a first compartment and a solution 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.

Description

I
Docket No. 2252 Description RAPID MIOSIS WIT71 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 2~ hours after surgery.
Backc_~~ound of the Invention Miotic agents are frequently used by ophthalmologic surgeons during intraacular 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 ensure 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 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 scle~al sutures, anterior chamber lens insertion and a decrease in post-operative peripheral anterior synechl,as. Many surgeons feel that miotic agents help in centering and positioning the intraocular lens implant.
Elevated intraocular pressure (TOP) can interfere with normal functioning and may result in irreversible loss of visual function. 'Viscvelastic agents such as ltealon 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 lOL's, I
I

more and more viscoelastic substances are being used.
Increasingly, cataract surgery is being done on an out-patient 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 Crave shown that the IoP in the first 24 hours after cataract surgery may be very important.
Damage by raising ToP is possible to the optic nerve, the vascular supply within the eye, and the corneal endothelium (15) (7). Consequently, every effort should be made to control the IOP from the very onset of the post-operative period.
~lcetylcholine (Miochol) is the most popular miotic agent utilized by ophthalmologic surgeons. Miochol provides quick miosis (within minutes). However, it provides very poor control of ToP after several hours, even when pressure control agents such as acetazvlamide (Diamox) are utilized.
Carbachol (Miostat) does not provide as quick a miosis and is nvt as widely used. ~. miotic agent providing quick miosis with control of intraocular pressure 24 xraure after surgery is noeded.
Dasori~t~.on of t~ra P,~;~or ~,r~
Gormaz (3), in 1962, first reported increases in IoP in tire immediate period after cataracts extractions. Rich (4) (5) in 1968 and 1969 found a significant rise in IoP was characteristic after cataract surgery. die also showed that --chymotrypsirl was not required to produce this increase.
Sodium hyaluronate (~iealon) has been implicated as causing a rise in IoP. olivius and T'hornburrr (6) have shown that sbd~ium hyalurbnate induced increased IoP, arid is partially i n , ~'w..-~ ~~~v.r' reversible by removal or ~ dilutian of the viscr~e~.astic material by irrigation (7).
Several drugs have been used to counteract the increase in TOP associated with cataract surgery. Rich (3) in 1969 demonstrated a lowering of TOP 24 hours after surgery with the use of acetazolamide (Diamox) in high doses during the 2~1 hours following cataract surgery. However, acetazolamide has some undesirable side effects in some patients.
Although Timolal effectively lawered TOP after TCCE (S), it ZO was found to have no effect in acute post-operative pressure elevations following ECCE with IOL and the use of sodium hyaluronate (9). Decently, a simple administration of pilocarpine gel was found to be effective in reducing IoP
for the first 24 hours after ECCE with TOL (10). f3owever, patients frequently complained of brow ache the next day.
This same group, however, felt that there was a trend in lowering ToP post-operatively using Timalol.
Ndiotic agents came into use in about 1970, shortly after the onset of ECCE. Tn 1972, Beasley (11) found that miosis was rapid with both acetylcholine 1% and Carbachvl .OZ%. With Carbachol, miosis extended into the first post-operative day, unlike acetylcholine, where 'the miotic effect is gone within a very short tune. however, Iiolland, Drance and Schulzer (13) , showed that acetylcholine 1% has a mare rapid anset o~ miasis than does Carbachol .o1%, Holland, Drance and Schulzer (14) showed that acetylctroline 1%, administered intracamerally during cataract surgery, significantly reduced the TOP at 3 and 5 hours post-operatively but had no effect beyond this time. On the other hand, this same group of investigators showed that Carbachol .O1% was highly effective in reducing 30P for at least 24 hours post--operatively, and in reducing the number of patients developing TOp greater than 3omm.~ig.
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BIBLIOGRAP~IY
(1) U.S. Patent NO. 4,459,309 --(2) U.S. Patent No. 4,665,094 ~(3) Gormaz, A.: Ocular Tension After cataract Suraerv.
American Journal of Ophthalmology, 43:832, 1962.
w(4) Rich, W.J.C.C.: ~ntr_aQCUIa~ lP~essures and Wound Closure After Cataract Extract$on. Traps. Ophthalmol.
Soc., U.K. 88:437, 1968.
~(5) Rich, W.J.C.C.: Further Studies on Early Post operative Ocular Iiyyertension Followinu Cataract Extraction. Traps. Ophthalmol. Soc., U.K. 89:639, 1969.
~(6) Olivius, E., and Thornburn, W.: Tntraocular Pressure After Sur~ry with Healon. Am. Intraocular Implant soa. J. 11:480, 1985.
~(7) Cher~an, G.M., Rich, W.J. and Wright, G.: Raised Intraocular Pressure and Other Problems with Sodium Iivaluronate and Cataract Surae~. Traps. Ophthalmol.
Soc., U.K. 103:277, 1983.
~(8) obstbaum, S.A. and Galin, M.A.: The Effects of Timo7,o1 on Cataract Extraction and Intraocular Pressure. Am. J. Ophthalmol. 88:1017, 1979.
'~.(9) Tomoda, 7C. , Tuberville, A.W. , and Ward, 'f.(7. :
Timolol_and_ Posto a at v~ I~raoc~lar Presser~.
Am. Intraocul. Implant Soc. J., 10:180, 1984.
x(10) Ruiz, R.S., Wilson, C.A., Musgrove, K.II. and Prager, T.C.: M~nactement of Increased Ir~traocular Pressure After Cataract Extraction. Am. J. Ophthalmol., 103:487, 1987.
',(11) Heasley, H.: ~$otics In Cataract SurcLery. Arch.
Ophthalmol., 88:49, 1972.
x(12) Douglas, G.R.: A Comparison of Acetylcholine and Caxbachol I:'ollowina Cataract JEx rac ;ion. Can. ;I.
....t., Ophthalmol., 8:75, 1973.

(13) Hollands, R.H. Drance, S.M., and Schulzer, M.: The Effect of Intracamerol Carbachol on Intraocular Pressure After Cataract Extraction. Am. J.
Opthalmol., 104:225, 1987 (14) Hollands, R.N., Drance, S.M., and Schulzer, M.: The Effect of Acetylcholine on Early Postoperative Intraocular Pressure. Am. J. Ophthalmol., 103:749, 1987.
(15) Hayrch, S.S.: ~nteriQr Ischemic Optic Neuropathy.
~y, occurrence After Cataract Extraction. Arch.
Ophthalmol., 98:1410, 1980.
Statement of the Inyention An improved miotic agent is provided in accordance with this invention that provides rapid miosis with 24 hour control of intraocular pressure. The miotic agent of the invention reduces or eliminates the need for IOP control agents such as *Diamox and reduces IOP after use of viscoelastic agents such as Nealon.
The miotic agent of the invention 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 2~ 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 of the invention 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. The miotic agent of the invention 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.
*Trade-mark The acetylcholine and carbachol materials can be used sequentially or simultaneously. Another aspect of the invention resides in 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 Drawinus Figure la is an enlarged view of a package containing the component of the miotic agent of the invention;
Figure 1b is a view taken along line lb-lb of Fig. la;
Figure lc is a view similar to Fig. 1b 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 ir~traocular pressure IOP in a group of patients receiving *Miochol with l7iamox;
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 patients receiving Miostat without Diamox;
Figure 6 is a set of curves showing pre-operative and post-operative intraocular pressure zOP in a group of glaucoma patients receiving Miochol;
*Trade-mark 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 Descrivtion of the Invention The first active agent in the miotic composition of the invention is a compound of the formula:
l0 R X+ ~ ~ ~ ~ 1 R N ~.-- C C O C R
R H Ii where R and Rl are lower alkyl groups containing 1 to 5 carbon atoms and X- is an anion such as halo.
The preferred member of this group is acetylcholine where R and R1 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 physiologically inert, liquid carrier before use. The dry material can be mixed with an inert lyophizing material such as mannitol in ratios of 1/1 to 10/1, usually 3/1 by weight. The reconstituted 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:

2 + I I
R N j - f O C ( CH2 ) n NH

where R2 is a low alkyl group of 1-5 ca,7~~on atoms, n is an integer from 0-3 and X is an anion such as halo. The *Trade-mark m I I' i preferred material carbactrol, is a oc~mpound in which rr is o, R2 are all methyl and X is chloro. Carbachol is provided as a sterile aqueous salt solution in a concentration from o.ool to 1.o percent by weight, usually at about o.ol~ by weight. The isotonic salt carrier includes the following inactive salts:
,~ b~, ~~i~
PIaCl 0. 64 KCl O.o75 GaCl2 &Tao 0. o4t~
. 6 ~
MgCl 0 03 2 2 .

sodium acetate 3~IZO o.39 sodium citrate 2H2o 0.17 The pH is adjusted to neutral with sodium hydroxide or " hydrochloric acid as needed.
Referring now to Figure 1, tire 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 1~L contains a unit dosage or charge 20 of l% the first agent such as acetylcholine and the lyophizing agent such a mannital and tire second compartment 17 contains an aqueous solution 22 of the second agent in a solution of salt in isotonic proportionb and concentrations. I'he plunger-stopper 16 is pressed downwardly which forces the plug 18 into the lower compartment. The plunger-stopper lc comes to rest on tire shoulder 25 formed slang the rim 27 of the annular section 31 of the uni-vial l0. The solution 22 3o falls into the first compartment 1~1 and dissolves the dry charge 20. In use, a hypodermic needle, not shown, is inserted thrpugh tire plunger-stopper 15 into the second compartment 17 to withdraw the solution. lifter 'the dry mixture of compounds is dissolved, the combined miotic agent is withdrawn into the syringe and is re~~~ for use.

~'', ~.! x~l t;~ .~~.. F.~, (,f Studies were conducted u~aing M~oc:hol (Aaetyleholinej and Miostat sequentially, and combined separately during intraocular surgical procedures.
The miotic agent of the invention 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 infected. 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 ohamber. As the last stitching of the incision is completed, the iris is examined for roundness and for inclusion of iris or capsular tags in the incision.
Then the combination of ac~tylcholine 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 viscvelastic agent is aspirated from the anterior chamber and the combination miotic agent is 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 lOP control without the use of Diamox and excellent control of glaucoma patiento undergoing SCCT~:.
The average intraocular dose of Miochol is o.5 to ~ ml of the 1~ solution and of the Carbactaol during surgery is 0.5 to 2 ml of a 0.01 solution.
The intraocular pressure was measured with the Coldman ~U applanation tonometer the day before surgery dur:lng the pre operative visit. The second intraocular pressure measurement was taken 2U-24 hours after surgery at the first post-operative visit.
s;

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: (a) Nonan cuff 15-30 minutes pre-operatively, (b) approximately 11 mm incision, (c) manual extracapsular cataract extraction (pressure below, counter-pressure above), (d) Nealon (sodium hyaluronate) was used in all cases, (e) machine cortical irrigation and aspiration containing Epinephrine with either Site unit or Series 10,000 Coopervision unit, (f) ~~in the bag~~ placement of the posterior chamber intraocular lens, (g) machine irrigation and aspiration of Nealon, (h) Miotic agent instilled into the anterior chamber and the chamber was aspirated to remove the Nealon, (i) closure with interrupted l0-0 nylon sutures.
In~ectable medication used at surgery were Garamycin (1/2 to 1 cc), and *Celestone ('~ 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 mioais followed by rapid lowering of IOP and low IOP after 24 hours.
The following table and Figure 8 show the IOP 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.
*Trade-mark ..~ ~. ~. ' , ,,..,.
(1 4~ ~ L"; .n.. 4 t.) Patie ~'3~~.~~ I~~

7 16 to -6 l0 8 1g 16 The combined mio~i~ ~gsr~~ o~ ~lae invention was administered to 18 additional subaects. Measurements of I~P
were taken on the operated eye (DP) and the fellow (F'EL) eye before the operation at surgery (JPR~) and 24 hours after t~~e operation (POSfi). The pupil sire was measured at surgery (AT) and 24 hours after surgery (POST). x'he following Table shows the measurements, the differences (DRLTA) and the maximum,, minimum and averages of the measurements.

t~~r huplldeltw pelt i1 Pa~~e_nt &~~.!'~JL b~ ~'~ ~~'fi~p ..l'F.L
~x~QD

1 14 ' 1A 13 11 $.J 2 -1 -7 7. 22 23 12 2d $ $ -10 3 2p a l0 1A 10 13 '3 1.9 2 A 19 19 A 13 $ 2.3 -1.6 -A

21 to ~3 1~ $ 1.9 A U

zo z0 21 17 3 2 1 -7 a 16 17 16 1$ 3.~ a o ,;--3 9 l0 17 l0 1z 2.5 2.5 0 ~-s . to is 1G ' $ ie ~ 3 -lz o 11 to al s xo ~ a -la -1 Iz 16 1G 1~ 1d 4 a 2 2 11 la 1A 1d 16 6 a 9 x 1A 1o ao 19 a6 a.~ 2 a 6 15 16 16 . 16 13 $ 2.3 o -!

is 19 19 15 10 3 ~ -7 -~t 17 1A 15 10 to a.B 7 A 3 Mnx.22 27 ~~ 26 6 4 9 G

Mln.13 18 $ 10 2.J ~.3 -18 -5 nve.17.27~ 17.56561$.944 1P>.~331:9.~1 a.198-2.3a3-0.77.212 STD ?..869~ 2.$78675.805$ $.23994O.A2 0.3725.99037.r)886971 'I'!le PGStOp TO$~ lt)wl~rthin ~~~-Ob i~ ~h~ ~O~
~htlw~.llg ~lo''; good PChe~ il is still 24 hours control. pup constricted later.

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a. ~
retroepeat~.ve, oliniC~l Study Wye conducted on pre-operative and post~operat~.ve intraoeular pressures of patients administered l~cetylcholine or Carbachol while undergoing extracapsular, cataract extraction with intraocular lens implantation. The surgery Bias 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.
Tn the early stages of this retrospective study, it became apparent that post-operative pressure spikes occurring 20-24 hours later were of a mayor concern. This retrospective study compares the post-operative intraocular pressure (IOP) in 4 groups following standard extracapsular cataract extraction with intraocular lens (FCCE with IOL).
The 4 groups consisted of Miochol (acetylcholine chloride) alone, Miochol with 500mg. Diamox (acetazolamide) giver orally at 1800 hours, Miostat (Carbachol) with 50omg. 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 wittx or without Diamox.
Figures 4 and 5 show that ttae patients treated with Mio~stat with or without IUiamox had good control of :~Op.
Surprisingly, the graup not receiving D:Lamox had better control.
The patients given Miochol only had an average pre operative intraocular pressure of 14.2 and an average post operative pressure of 2g.5. However, 4 of these 11 patients had pressure spikes of over 30, and 1 of 4Rmmtig. The average increase in intraocular pressure was 12.3mmHG.
patients were given Miochol at the time of surgery with 50omg. of Diamox orally at 1800 hours on the day ref 35 surgery, in an attempt to reduce pre~~tire spikes. The L_a 1~ > z ~'~ sn ~~~,~!~ P ~dU
average post-operative pressuxe was 20.1 with an average increase of 6.8mmiig. of pressure. iiawever, in this group, there were 9 of 35 patients with intraocular pressure of above 25 to a high cg 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.g, and the average increase in intraocular pressure was 2.3mm.
only 3 of 38 patients had pressures over 25, the highest 1.0 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. Dnly 1 of 36 patients had a post-operative intraocular pressure of over 25. This group appeared to be elinical~y at least as well controlled as the P3iostat with Diamox group, and certainly superiorly controlled to the Miochol group.
2p During this retrospective study, 16 known cases of glaucoma were uncovered -- an admittedly small group. 7Ai1 glaucoma cases were on medication and felt to be cantrolled, although 2 patients, 1 in each group, did have a pre-operative pressure of 25. 8 of these patients had been given Miochol at surgery, and 8 had been given Mioatat. X11 of these patients received Diamox 50omg. at 1800 hours the day of surgery. (a) 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 Celes.n~ne. (e) Topical medications used upon completion at surgery were Tobrex, ax deb, and ~etoptic, 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 MioCil01 at surgery. The av~xage pre-operative 'r.t~ r,.3 J c~9 intraocular pressure was 21, t~ttd tl~e average post-operative intraocular pressure was 3l, an increase of 16.3mm. 7 of the ~ patients had intraocular pressures of 30 or over, one patient°s pressure spiked to 54mm.
Figure 7 shows the data for ttie n patients who had been given Miostat at surgery. dlverage 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.
l0 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 standard ECCE supports the safety and efficacy of the combined miotic agent of the invention. The miotic agent containing both Miochol and Miostat (carbachol .O1%) appears to be a superior pharmacological agent to one cowtaining Miochol (acetylcholine chloride 1%) in controlling IoP 20-24 hours later, as measured by applanation tonometry. In the routine care of standard ECCE witty 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 oases, the miotic agent of the invention should be effective in providing quick miosis while controlling post-operative lOP 20-24 hours ~.ater.
It is to b0 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 cla~.ms.

Claims (18)

1. Use of a first miotic agent selected from components of the formula:

where R and R1 are lower alkyl groups containing 1 to 5 carbon atoms and X- is an anion; and a second miotic agent selected from components of the formula:

where R2 is a low alkyl group of 1-5 carbon atoms, n is an integer from 0-3 and X is an anion, for the induction of quick miosis and control of intraocular pressure.

2. The use according to claim 1 in which R and R1 are methyl and X- is chloro.

3. The use according to claim 2 in which R2 is methyl, n is 0 and X- is chloro.

4. The use according to claim 3 in which the two agents are used sequentially.

5. The use according to claim 4 in which the first agent is used before the second agent.

6. The use according to claim 3 in which the two agents are used simultaneously.

7. The use according to claim 3 in which the first agent is dissolved in a pharmacologically acceptable aqueous carrier in a concentration from 0.1 to 5% by weight.

8. The use according to claim 7 in which the solution of first agent further includes a lyophizing material in a weight ratio to agent of 1/1 to 10/1.

9. The use according to claim 8 in which the lyophizing material is mannitol present in an amount of about 3% by weight.

10. The use according to claim 7 in which the second agent is dissolved in a pharmacologically acceptable isotonic aqueous saline in an amount from. 0.001 to 1.0 percent by weight.

11. The use according to claim 10 in which the second agent is present in the saline solution in an amount of about 0.01% by weight.

12. The use according to claim 11 in which both miotic agents are dissolved in the pharmacologically acceptable aqueous saline as a common carrier.

13. The use according to claim 12, wherein said first and second miotic agents are used in extracapsular cataract extraction intraocular lens implant surgery.

14. A unit dosage package of a combination miotic capable of quick miosis while controlling intraocular pressure comprising:
a first sterile container containing a unit dosage of a first miotic agent in dry powder form selected from components of the formula:

where R and R1 are lower alkyl groups containing 1 to 5 carbon atoms and X- is an anion; and a second sterile container containing unit dosage of a solution of a second miotic agent selected from components of the formula:

where R2 is a low alkyl group of 1-5 carbon atoms, n is an integer from 0-3 and X is an anion in an aqueous saline which is a solvent for the first miotic agent.

15. A package according to claim 14 in which the containers are physically joined.

16. A package according to claim 15 in which the containers are joined by an elastomer seal penetrable by a hypodermic needle.

17. A package according to claim 14 in which R and R1 are methyl and X- is chloro.

18. A package according to claim 17 in which R2 is methyl, n is 0 and X- is chloro.