- Email: [email protected]
Healon5 sandwich technique for phacoemulsification in vitrectomized eyes
TECHNIQUE
Healon5 sandwich technique for phacoemulsification in vitrectomized eyes Rajeev Sudan, MD, Rajamani Muralidhar, MD, DNB, FRCS, MRCOphth, Vikas Sharma, MD, MRCSEd, MRCOphth
We have developed a safe approach to phacoemulsificaiton in post-vectromized eyes. The technique, called the Healon5 sandwich, uses the viscoadaptive properties of sodium hyaluronate 2.3% (Healon5) to prevent a posterior chamber dehiscence. J Cataract Refract Surg 2008; 34:18–20 Q 2008 ASCRS and ESCRS
Vitrectomized eyes challenge the skills and clinical judgment of the cataract surgeon. The absence of a peripheral vitreous skirt can result in a fluctuating anterior chamber. The posterior capsule movement can result in high rates of posterior capsule dehiscence, especially during emulsification of the last fragment. Zonular weakness and spontaneous capsulodonesis may be present.1 Ophthalmic viscosurgical devices (OVDs), especially the sodium hyaluronate (Healon) series, are used to stabilize the anterior chamber. Although the existing cohesive OVDs can maintain the anterior chamber, they cannot remain in the eye during phacoemulsification. A new viscoadaptive OVD, sodium hyaluronate 2.3% (Healon5), has been developed to change its behavior at different flow rates: It acts as a viscous cohesive OVD at low flow rates and as a pseudodispersive OVD at high flow rates.2 We have used this viscoadaptive property to develop the Healon5 sandwich technique to minimize the occurrence of posterior capsule dehiscence in postvitrectomized eyes. SURGICAL TECHNIQUE The procedure is performed under peribulbar anesthesia. The eye is cleaned with povidone–iodine 5% (Betadine), covered with a sterile drape, and an OpSite Accepted for publication September 30, 2007. From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Vikas Sharma, MD, MRCSEd, MRCOphth, 18 Wakefield Crescent, Standish, Wigan, WN6 0AU, United Kingdom. E-mail: [email protected].
18
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
dressing (Smith & Nephew) is placed. The lids are separated with a universal eye speculum. The anterior chamber is entered with a 3.2 mm keratome, and a side port is made with an MVR blade about 2 clock hours away. The ultimate soft-shell technique3,4 is used to perform capsulorhexis: The anterior chamber is filled with Healon5, and 0.1 mL of balanced salt solution is injected under the OVD. In a case of white cataract, trypan blue dye is used. A capsulorhexis of approximately 5.0 mm diameter is performed with a 26-gauge needle. The OVD is partially removed from the anterior chamber by pressing the posterior lip of the incision. Cortical cleaving hydrodissection and hydrodelineation are then performed. Phacoemulsification is performed with a 30-degree tip by the slice-and-separate technique5 using the Alcon Universal II machine. Initial power settings depend on the anticipated hardness of the nucleus. The flow rate is kept at 25 cc/min and suction at 150 mm Hg. The phaco probe is buried deep in the center of the nucleus. The nucleus is sliced with a sharp chopper, and the pieces are rotated 90 degrees. The inferior piece is engaged by the phaco probe and bisected. Depending on the hardness of the cataract, more pieces may be created. After half the nucleus is emulsified, the second piece is rotated into the inferior position. At this stage, the phaco probe is withdrawn from the anterior chamber. Healon5 is injected under the nucleus to push the posterior capsule down and gently lift the nuclear fragments. Then, 0.1 mL of Healon5 is injected above the nuclear pieces to prevent them from prolapsing out of the bag. This in effect stabilizes the nucleus and holds it in position between a ‘‘sandwich’’ of Healon5. The flow rate is reduced to 18 cc/min and vacuum to 100 mm Hg. The phaco probe is reintroduced into the anterior chamber without turning on the infusion. This technique helps retain Healon5 in the 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2007.09.014
TECHNIQUE: HEALON5 SANDWICH FOR PHACO IN VITRECTOMIZED EYES
anterior chamber. The tip abuts the inferior piece; the foot pedal is moved to position 2 and the piece engaged. A sharp chopper is used to slice the inferior piece. One piece is engaged and emulsified. If the posterior capsule is stable, the procedure is repeated with the second piece. Otherwise, more Healon5 is injected under the nuclear pieces. Particular care is necessary while emulsifying the last piece. The irrigation/aspiration handpiece is used to remove the cortical matter, and the intraocular lens (IOL) is placed in the bag under the OVD. The OVD removal is achieved using the 2-compartment technique of Tetz and Holzer.6 Results The Healon5 sandwich technique was used in a series of 13 patients. Ten patients had vitrectomy for non-clearing vitreous hemorrhage due to proliferative diabetic retinopathy, and the remaining 3 had tractional retinal detachment due to Eales disease. All the patients had an attached posterior pole on indirect ophthalmoscopy. In another 10 patients, sodium hyaluronate 3.0%–chondroitin sulfate 4.0% (Viscoat) was used instead of Healon5, maintaining the same parameters for removing the last piece. All 10 patients had non-clearing vitreous hemorrhages due to proliferative diabetic retinopathy and had vitrectomies. Cataract surgery was uneventful in all patients. No significant fluctuation of the anterior chamber was noted. Phacoemulsification was performed in the capsular bag and an IOL placed in each case. Two patients had simultaneous silicone oil removal through a tear in the posterior capsule at the end of surgery. Postoperatively, no patient developed elevated intraocular pressure. The final visual acuity was limited by the posterior segment pathology and ranged from 20/40 to 20/400. Our impression is that Healon5 imparted greater stability to the nuclear pieces and the posterior capsule than Viscoat. If the irrigation was accidentally turned on before the last piece was impaled, the nuclear fragment went deep into the bag when Viscoat was used, a problem that was not encountered with Healon5. However, we have not had any complications with Viscoat. DISCUSSION Ophthalmic viscosurgical devices have been used in cataract surgery to create space, stabilize tissues, pressurize the anterior chamber to balance posterior pressure, and protect endothelial cells. The elastic properties of sodium hyaluronate 1.0% (Healon) and sodium hyaluronate 1.4% (Healon GV) are sufficient to counter vitreous pressure and tamponade the anterior/posterior capsule, but these OVDs are not
19
retained in the anterior chamber at the commencement of phacoemulsification. The dispersive OVDs are not elastic enough for effective tamponade.7 Our technique exploits the superior viscoadaptive properties of Healon5. This OVD tends to behave as a superviscous cohesive substance at low flow rates; the cohesive properties are superior to those of Healon and Healon GV because of the higher percentage of sodium hyaluronate (2.3%). At high flow rates, however, the molecule tends to fracture and behave as a pseudodispersive substance, persisting in the anterior chamber and affording some endothelial protection. It is the only OVD other than Viscoat that is retained in the anterior chamber at all stages of phacoemulsification.8 High flow rates of 20 to 25 cc/min with high suction are needed to fracture the molecule and remove it from the anterior chamber. The rock ’n roll technique uses the side-to-side motion of the irrigation/aspiration tip.9 We therefore use a low flow rate and low vacuum to retain the OVD in the anterior chamber during phacoemulsification. The low flow rate would be expected to reduce followability, but we have not experienced any problems. Viscoat, in comparison, has a lower viscosity (41 000 cps compared with 200 000 cps of Healon5). While Viscoat might equal Healon5 in plugging vitreous in the event of a posterior capsule rupture, we believe it is inferior in sandwiching the last nuclear fragment, especially when irrigation is turned on prematurely. Due to its higher viscosity, Healon5 also has the greatest capacity to create and maintain space inside the eye.10 This helps create an artificial epinucleus that cushions the nucleus and separates it from the posterior capsule.11 This might be of value for the inexperienced surgeon. In experienced hands, however, the 2 OVDs may be equivalent. In conclusion, the unique properties of Healon5 permit retention in the anterior chamber by reducing the flow rate, which aids effective tamponade of the posterior capsule. Although we have used this technique in vitrectomized eyes only, the technique would be of value in any case with a floppy posterior capsule. REFERENCES 1. Weiser M. Cataract removal in eyes with previous vitrectomy: personal technique. In: Buratto L, Werner L, Zanini M, Apple D, eds, Phacoemulsification; Principles and Techniques 2nd ed. Thorofare, NJ, Slack, 2003; 554 2. Arshinoff SA, Wong E. Understanding, retaining, and removing dispersive and pseudodispersive ophthalmic viscosurgical devices. J Cataract Refract Surg 2003; 29:2318–2323 3. Arshinoff SA. Using BSS with viscoadaptives in the ultimate softshell technique. J Cataract Refract Surg 2002; 28:1509–1514 4. Arshinoff S. Capsule dyes and the USST [letter]. J Cataract Refract Surg 2005; 31:259–260 5. Arshinoff SA. Phaco slice and separate. J Cataract Refract Surg 1999; 25:474–478
J CATARACT REFRACT SURG - VOL 34, JANUARY 2008
20
TECHNIQUE: HEALON5 SANDWICH FOR PHACO IN VITRECTOMIZED EYES
6. Tetz MR, Holzer MP. Two-compartment technique to remove ophthalmic viscosurgical devices. J Cataract Refract Surg 2000; 26:641–643 7. Dick HB, Krummenaeuer F, Augustin AJ, et al. Healon5 viscoadaptive formulation: comparison to Healon and Healon GV. J Cataract Refract Surg 2001; 27:320–326 8. Tetz MR, Holzer MP, Lundberg K, et al. Clinical results of phacoemulsification with the use of Healon5 or Viscoat. J Cataract Refract Surg 2001; 27:416–420
9. Zetterstro¨m C, Wejde G, Taube M. Healon5: comparison of 2 removal techniques. J Cataract Refract Surg 2002; 28:1561–1564 10. Zanini M, Savini G, Buratto MDL. Ophthalmic viscosurgical devices and cataract surgery. In: Buratto L, Werner L, Zanini M, Apple D, eds, Phacoemulsification; Principles and Techniques 2nd ed. Thorofare, NJ, Slack, 2003; 207–218 11. Steinert RF. Dense brunescent cataract. In: Steinert RF, ed, Cataract Surgery; Technique, Complications, and Management. Philadelphia, PA, Saunders, 2004; 301–304
J CATARACT REFRACT SURG - VOL 34, JANUARY 2008
Healon5 sandwich technique for phacoemulsification in vitrectomized eyes Rajeev Sudan, MD, Rajamani Muralidhar, MD, DNB, FRCS, MRCOphth, Vikas Sharma, MD, MRCSEd, MRCOphth
We have developed a safe approach to phacoemulsificaiton in post-vectromized eyes. The technique, called the Healon5 sandwich, uses the viscoadaptive properties of sodium hyaluronate 2.3% (Healon5) to prevent a posterior chamber dehiscence. J Cataract Refract Surg 2008; 34:18–20 Q 2008 ASCRS and ESCRS
Vitrectomized eyes challenge the skills and clinical judgment of the cataract surgeon. The absence of a peripheral vitreous skirt can result in a fluctuating anterior chamber. The posterior capsule movement can result in high rates of posterior capsule dehiscence, especially during emulsification of the last fragment. Zonular weakness and spontaneous capsulodonesis may be present.1 Ophthalmic viscosurgical devices (OVDs), especially the sodium hyaluronate (Healon) series, are used to stabilize the anterior chamber. Although the existing cohesive OVDs can maintain the anterior chamber, they cannot remain in the eye during phacoemulsification. A new viscoadaptive OVD, sodium hyaluronate 2.3% (Healon5), has been developed to change its behavior at different flow rates: It acts as a viscous cohesive OVD at low flow rates and as a pseudodispersive OVD at high flow rates.2 We have used this viscoadaptive property to develop the Healon5 sandwich technique to minimize the occurrence of posterior capsule dehiscence in postvitrectomized eyes. SURGICAL TECHNIQUE The procedure is performed under peribulbar anesthesia. The eye is cleaned with povidone–iodine 5% (Betadine), covered with a sterile drape, and an OpSite Accepted for publication September 30, 2007. From the Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India. No author has a financial or proprietary interest in any material or method mentioned. Corresponding author: Vikas Sharma, MD, MRCSEd, MRCOphth, 18 Wakefield Crescent, Standish, Wigan, WN6 0AU, United Kingdom. E-mail: [email protected].
18
Q 2008 ASCRS and ESCRS Published by Elsevier Inc.
dressing (Smith & Nephew) is placed. The lids are separated with a universal eye speculum. The anterior chamber is entered with a 3.2 mm keratome, and a side port is made with an MVR blade about 2 clock hours away. The ultimate soft-shell technique3,4 is used to perform capsulorhexis: The anterior chamber is filled with Healon5, and 0.1 mL of balanced salt solution is injected under the OVD. In a case of white cataract, trypan blue dye is used. A capsulorhexis of approximately 5.0 mm diameter is performed with a 26-gauge needle. The OVD is partially removed from the anterior chamber by pressing the posterior lip of the incision. Cortical cleaving hydrodissection and hydrodelineation are then performed. Phacoemulsification is performed with a 30-degree tip by the slice-and-separate technique5 using the Alcon Universal II machine. Initial power settings depend on the anticipated hardness of the nucleus. The flow rate is kept at 25 cc/min and suction at 150 mm Hg. The phaco probe is buried deep in the center of the nucleus. The nucleus is sliced with a sharp chopper, and the pieces are rotated 90 degrees. The inferior piece is engaged by the phaco probe and bisected. Depending on the hardness of the cataract, more pieces may be created. After half the nucleus is emulsified, the second piece is rotated into the inferior position. At this stage, the phaco probe is withdrawn from the anterior chamber. Healon5 is injected under the nucleus to push the posterior capsule down and gently lift the nuclear fragments. Then, 0.1 mL of Healon5 is injected above the nuclear pieces to prevent them from prolapsing out of the bag. This in effect stabilizes the nucleus and holds it in position between a ‘‘sandwich’’ of Healon5. The flow rate is reduced to 18 cc/min and vacuum to 100 mm Hg. The phaco probe is reintroduced into the anterior chamber without turning on the infusion. This technique helps retain Healon5 in the 0886-3350/08/$dsee front matter doi:10.1016/j.jcrs.2007.09.014
TECHNIQUE: HEALON5 SANDWICH FOR PHACO IN VITRECTOMIZED EYES
anterior chamber. The tip abuts the inferior piece; the foot pedal is moved to position 2 and the piece engaged. A sharp chopper is used to slice the inferior piece. One piece is engaged and emulsified. If the posterior capsule is stable, the procedure is repeated with the second piece. Otherwise, more Healon5 is injected under the nuclear pieces. Particular care is necessary while emulsifying the last piece. The irrigation/aspiration handpiece is used to remove the cortical matter, and the intraocular lens (IOL) is placed in the bag under the OVD. The OVD removal is achieved using the 2-compartment technique of Tetz and Holzer.6 Results The Healon5 sandwich technique was used in a series of 13 patients. Ten patients had vitrectomy for non-clearing vitreous hemorrhage due to proliferative diabetic retinopathy, and the remaining 3 had tractional retinal detachment due to Eales disease. All the patients had an attached posterior pole on indirect ophthalmoscopy. In another 10 patients, sodium hyaluronate 3.0%–chondroitin sulfate 4.0% (Viscoat) was used instead of Healon5, maintaining the same parameters for removing the last piece. All 10 patients had non-clearing vitreous hemorrhages due to proliferative diabetic retinopathy and had vitrectomies. Cataract surgery was uneventful in all patients. No significant fluctuation of the anterior chamber was noted. Phacoemulsification was performed in the capsular bag and an IOL placed in each case. Two patients had simultaneous silicone oil removal through a tear in the posterior capsule at the end of surgery. Postoperatively, no patient developed elevated intraocular pressure. The final visual acuity was limited by the posterior segment pathology and ranged from 20/40 to 20/400. Our impression is that Healon5 imparted greater stability to the nuclear pieces and the posterior capsule than Viscoat. If the irrigation was accidentally turned on before the last piece was impaled, the nuclear fragment went deep into the bag when Viscoat was used, a problem that was not encountered with Healon5. However, we have not had any complications with Viscoat. DISCUSSION Ophthalmic viscosurgical devices have been used in cataract surgery to create space, stabilize tissues, pressurize the anterior chamber to balance posterior pressure, and protect endothelial cells. The elastic properties of sodium hyaluronate 1.0% (Healon) and sodium hyaluronate 1.4% (Healon GV) are sufficient to counter vitreous pressure and tamponade the anterior/posterior capsule, but these OVDs are not
19
retained in the anterior chamber at the commencement of phacoemulsification. The dispersive OVDs are not elastic enough for effective tamponade.7 Our technique exploits the superior viscoadaptive properties of Healon5. This OVD tends to behave as a superviscous cohesive substance at low flow rates; the cohesive properties are superior to those of Healon and Healon GV because of the higher percentage of sodium hyaluronate (2.3%). At high flow rates, however, the molecule tends to fracture and behave as a pseudodispersive substance, persisting in the anterior chamber and affording some endothelial protection. It is the only OVD other than Viscoat that is retained in the anterior chamber at all stages of phacoemulsification.8 High flow rates of 20 to 25 cc/min with high suction are needed to fracture the molecule and remove it from the anterior chamber. The rock ’n roll technique uses the side-to-side motion of the irrigation/aspiration tip.9 We therefore use a low flow rate and low vacuum to retain the OVD in the anterior chamber during phacoemulsification. The low flow rate would be expected to reduce followability, but we have not experienced any problems. Viscoat, in comparison, has a lower viscosity (41 000 cps compared with 200 000 cps of Healon5). While Viscoat might equal Healon5 in plugging vitreous in the event of a posterior capsule rupture, we believe it is inferior in sandwiching the last nuclear fragment, especially when irrigation is turned on prematurely. Due to its higher viscosity, Healon5 also has the greatest capacity to create and maintain space inside the eye.10 This helps create an artificial epinucleus that cushions the nucleus and separates it from the posterior capsule.11 This might be of value for the inexperienced surgeon. In experienced hands, however, the 2 OVDs may be equivalent. In conclusion, the unique properties of Healon5 permit retention in the anterior chamber by reducing the flow rate, which aids effective tamponade of the posterior capsule. Although we have used this technique in vitrectomized eyes only, the technique would be of value in any case with a floppy posterior capsule. REFERENCES 1. Weiser M. Cataract removal in eyes with previous vitrectomy: personal technique. In: Buratto L, Werner L, Zanini M, Apple D, eds, Phacoemulsification; Principles and Techniques 2nd ed. Thorofare, NJ, Slack, 2003; 554 2. Arshinoff SA, Wong E. Understanding, retaining, and removing dispersive and pseudodispersive ophthalmic viscosurgical devices. J Cataract Refract Surg 2003; 29:2318–2323 3. Arshinoff SA. Using BSS with viscoadaptives in the ultimate softshell technique. J Cataract Refract Surg 2002; 28:1509–1514 4. Arshinoff S. Capsule dyes and the USST [letter]. J Cataract Refract Surg 2005; 31:259–260 5. Arshinoff SA. Phaco slice and separate. J Cataract Refract Surg 1999; 25:474–478
J CATARACT REFRACT SURG - VOL 34, JANUARY 2008
20
TECHNIQUE: HEALON5 SANDWICH FOR PHACO IN VITRECTOMIZED EYES
6. Tetz MR, Holzer MP. Two-compartment technique to remove ophthalmic viscosurgical devices. J Cataract Refract Surg 2000; 26:641–643 7. Dick HB, Krummenaeuer F, Augustin AJ, et al. Healon5 viscoadaptive formulation: comparison to Healon and Healon GV. J Cataract Refract Surg 2001; 27:320–326 8. Tetz MR, Holzer MP, Lundberg K, et al. Clinical results of phacoemulsification with the use of Healon5 or Viscoat. J Cataract Refract Surg 2001; 27:416–420
9. Zetterstro¨m C, Wejde G, Taube M. Healon5: comparison of 2 removal techniques. J Cataract Refract Surg 2002; 28:1561–1564 10. Zanini M, Savini G, Buratto MDL. Ophthalmic viscosurgical devices and cataract surgery. In: Buratto L, Werner L, Zanini M, Apple D, eds, Phacoemulsification; Principles and Techniques 2nd ed. Thorofare, NJ, Slack, 2003; 207–218 11. Steinert RF. Dense brunescent cataract. In: Steinert RF, ed, Cataract Surgery; Technique, Complications, and Management. Philadelphia, PA, Saunders, 2004; 301–304
J CATARACT REFRACT SURG - VOL 34, JANUARY 2008