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Two-compartment technique to remove ophthalmic viscosurgical devices
techniques
Two-compartment technique to remove ophthalmic viscosurgical devices Manfred R. Tetz, MD, Mike P. Holzer, MS ABSTRACT To avoid postoperative intraocular pressure peaks, complete removal of all ophthalmic viscosurgical devices (OVDs) used during cataract surgery is important. Depending on the kind of OVD used, different removal techniques have been applied. We describe a technique that was used in more than 250 eyes for safe removal of OVDs, especially viscoadaptive OVDs such as sodium hyaluronate 2.3% (Healon姞5). It takes advantage of the viscoadaptive properties of Healon5 and was named the 2-compartment technique. J Cataract Refract Surg 2000; 26:641– 643 © 2000 ASCRS and ESCRS
A
wide armamentarium of ophthalmic viscosurgical devices (OVDs) is currently available for surgical use. These devices may be classified according to their intraoperative surgical and physical behaviors. These classifications are shown in Table 1. Complete and thorough removal of any OVD is important to avoid intraocular pressure (IOP) peaks postoperatively. In addition, OVD capture behind the IOL optic can only be prevented by thorough removal of the OVD from the capsular bag.1– 4 Several techniques to safely and completely remove OVDs from the anterior segment have been described.5,6 One widely applied technique is the rock ’n roll (S.A. Arshinoff, MD, “Rock ’n Roll Removal of Healon GV,” video presented at the Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, June 1996; G.U. Auffarth, MD, et al., “Evaluation of Different Removal Techniques of a HighViscosity Viscoelastic,” presented at the Symposium on
Accepted for publication October 6, 1999. Neither author has a financial interest in any product or technique mentioned. Reprint requests to Prof. Dr. med. M.R. Tetz, University Eye-clinic Charite´, Augustenburger Platz 1, 13353 Berlin, Germany. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 1994). We describe a method, the 2-compartment technique, for safe and complete removal of OVDs, especially viscoadaptive agents such as sodium hyaluronate 2.3% (Healon威5). Surgical Technique The technique described is for removing Healon5. Removal starts directly after intraocular lens (IOL) implantation while the anterior chamber is still filled with the viscoadaptive OVD and ideally before the IOL has been centered. The aspiration port, using a 1-handed or 2-handed technique, is placed facing the cornea. The handpiece is positioned behind the IOL optic without engaging flow. Aspiration tips are placed behind the IOL optic in a dry stage starting “dry and down under.” With a standard irrigation/aspiration (I/A) tip and a 0.3 mm aspiration port, the effectual flow setting is normally kept at 20 to 25 mL per minute and the vacuum setting about 250 to 300 mm Hg, with a potential maximum setting at 500 mm Hg. Bottle height should be around 60 to 70 cm above eye level. Flow is not engaged until the I/A tip has been positioned behind the IOL optic. Thus, the tip is initially protected by the surrounding OVD, as with any surgical instrument (Figure 1). 0886-3350/00/$–see front matter PII S0886-3350(00)00420-4
TECHNIQUES: TETZ
Figure 1. (Tetz) In the first step of the 2-compartment technique, the I/A tip is placed behind the IOL optic with the IOL still slightly decentered (starting dry down under).
Figure 2. (Tetz) The I/A tip, aspiration port up, is positioned and the flow engaged. The capsular bag is emptied and the viscoadaptive OVD removed as the anterior chamber remains filled and stabilized by Healon5. The bag is inflated by the irrigation flow, and the posterior capsule is held at distance.
After the viscoadaptive OVD is completely removed from the capsular bag, which can be easily visualized because of the high refractive index of Healon5, the tip is removed from behind the optic by continuing flow and placed on top of the optic, aspiration port facing upward. The removal is continued by circling the I/A tip at the iris plane or on the optic surface, and the OVD is visualized as it is removed (Figure 3). A final sweep may be made along the anterior chamber angle to remove remaining OVD. Figure 3. (Tetz) In the second step of the 2-compartment technique, the viscoadaptive OVD is removed from the second compartment, the anterior chamber.
The flow is started only after the IOL optic rim has been arrested against the sleeve or tip’s irrigation chamber. Thus, the viscoadaptive OVD is removed from the capsular bag first while the anterior chamber remains filled and the iris stabilized by the Healon5. The I/A flow takes place within the capsular bag while the viscoadaptive OVD maintains the anterior chamber and prevents fluids from coming forward (Figure 2). The posterior capsule is held at distance by the irrigation fluid, which is continuously inflating the capsular bag and preventing the posterior capsule from coming forward. Thus, the risk of inadvertently aspirating the posterior capsule is avoided. 642
Results Using the 2-compartment technique reduced the removal time of Healon5 in our surgical setting from a
Figure 4. (Tetz) Removal time for Healon5 using the 2-compartment and rock ’n roll techniques (N ⫽ 30; 1 surgeon; partially influenced by surgeon’s learning curve).
J CATARACT REFRACT SURG—VOL 26, MAY 2000
TECHNIQUES: TETZ
Discussion
Table 1. Overview of cohesive and dispersive viscoelastic materials.
Rating and Viscolastic
Zero-Shear Viscosity (mPas)
Superviscous cohesive Healon5
7.0 M
MicroVisc Plus
4.8 M
Healon GV
2.0 M
Viscous cohesive MicroVisc
1.0 M
Allervisc Plus
500.0 K
Provisc
255.0 K
Healon
230.0 K
Biolon
215.0 K
Allervisc
200.0 K
Amvisc
100.0 K
Amvisc Plus
100.0 K
Medium viscous dispersive Viscoat
41.0 K
Cellugel
38.0 K
Vitrax
25.0 K
Low viscous dispersive Ocuvisc
4.3 K
Ocucoat
4.0 K
Hymecel
4.0 K
Adatocel
4.0 K
Visiolon
4.0 K
The use of OVDs in cataract surgery is important in ensuring a safe and controlled procedure. However, OVD-induced complications after surgery may occur. Important among these are IOP peaks during the first 24 hours postoperatively and capsular bag distention syndrome.1– 4 To minimize these complications, complete, safe, and fast removal of OVDs is required. Depending on their physical and biochemical properties, viscoelastic materials may require different removal techniques. Ophthalmic viscosurgical devices have been categorized into 2 groups: cohesive and super cohesive (e.g., Healon, Healon GV) and dispersive (e.g., Viscoat and Ocucoat威 [hydroxypropyl methylcellulose]).4 New viscoadaptive OVDs, such as Healon5, may be best removed by the 2-compartment technique. The space-maintaining capacities of Healon5 in the anterior chamber are used while the OVD is being removed from the capsular bag. In the second step, the anterior chamber is cleaned. As new OVDs are introduced, surgeons continue to adapt steps of their procedure to the new features of the substances. Although it is still impossible to completely remove some dispersive OVD from the eye, the 2-compartment technique allows fast and complete removal of viscoadaptive OVDs.
References
M ⫽ million; K ⫽ thousand
mean of 44 seconds (Figure 4) using the rock ’n roll technique to 18 seconds. The 2-compartment technique was used over 5 months in more than 250 eyes. No eye had a severe IOP spike or posterior capsule rupture. The technique can also be used to easily remove any OVD such as methylcellulose, sodium hyaluronate (Healon威), and sodium chondroitin sulfate–sodium hyaluronate (Viscoat威) because of the method’s additional advantage of having the OVD in the anterior chamber while the capsular bag is being cleaned. However, the technique works best with a viscoadaptive OVD because of its high space-maintaining capacity at low shear rates, which keeps the anterior chamber filled until the bag is free of the OVD.
1. Kohnen T, von Her M, Schu¨tte E. Postoperativer Druckverlauf in den ersten Tagen nach intraokularem Einsatz von Hyaluronsa¨urelo¨sung mit unterschiedlicher Viskosita¨t. Klin Monatsbl Augenheilkd 1995; 207:29 –36 2. Kohnen T, von Her M, Schu¨tte E, Koch DD. Evaluation of intraocular pressure with Healon and Healon GV in sutureless cataract surgery with foldable lens implantation. J Cataract Refract Surg 1996; 22:227– 237 3. Miyake K, Ota I, Ichihashi S, et al. New classification of capsular block syndrome. J Cataract Refract Surg 1998; 24:1230 –1234 ¨ bersicht. New 4. Dick B, Schwenn O. Viskoelastika; Eine U York, NY, Springer, 1998; 19,73–77 5. Assia EI, Apple DJ, Lim ES, et al. Removal of viscoelastic materials after experimental cataract surgery in vitro. J Cataract Refract Surg 1992; 18:3– 6 6. Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg 1999; 25:167–173
J CATARACT REFRACT SURG—VOL 26, MAY 2000
643
Two-compartment technique to remove ophthalmic viscosurgical devices Manfred R. Tetz, MD, Mike P. Holzer, MS ABSTRACT To avoid postoperative intraocular pressure peaks, complete removal of all ophthalmic viscosurgical devices (OVDs) used during cataract surgery is important. Depending on the kind of OVD used, different removal techniques have been applied. We describe a technique that was used in more than 250 eyes for safe removal of OVDs, especially viscoadaptive OVDs such as sodium hyaluronate 2.3% (Healon姞5). It takes advantage of the viscoadaptive properties of Healon5 and was named the 2-compartment technique. J Cataract Refract Surg 2000; 26:641– 643 © 2000 ASCRS and ESCRS
A
wide armamentarium of ophthalmic viscosurgical devices (OVDs) is currently available for surgical use. These devices may be classified according to their intraoperative surgical and physical behaviors. These classifications are shown in Table 1. Complete and thorough removal of any OVD is important to avoid intraocular pressure (IOP) peaks postoperatively. In addition, OVD capture behind the IOL optic can only be prevented by thorough removal of the OVD from the capsular bag.1– 4 Several techniques to safely and completely remove OVDs from the anterior segment have been described.5,6 One widely applied technique is the rock ’n roll (S.A. Arshinoff, MD, “Rock ’n Roll Removal of Healon GV,” video presented at the Symposium on Cataract, IOL and Refractive Surgery, Seattle, Washington, USA, June 1996; G.U. Auffarth, MD, et al., “Evaluation of Different Removal Techniques of a HighViscosity Viscoelastic,” presented at the Symposium on
Accepted for publication October 6, 1999. Neither author has a financial interest in any product or technique mentioned. Reprint requests to Prof. Dr. med. M.R. Tetz, University Eye-clinic Charite´, Augustenburger Platz 1, 13353 Berlin, Germany. © 2000 ASCRS and ESCRS Published by Elsevier Science Inc.
Cataract, IOL and Refractive Surgery, Boston, Massachusetts, USA, April 1994). We describe a method, the 2-compartment technique, for safe and complete removal of OVDs, especially viscoadaptive agents such as sodium hyaluronate 2.3% (Healon威5). Surgical Technique The technique described is for removing Healon5. Removal starts directly after intraocular lens (IOL) implantation while the anterior chamber is still filled with the viscoadaptive OVD and ideally before the IOL has been centered. The aspiration port, using a 1-handed or 2-handed technique, is placed facing the cornea. The handpiece is positioned behind the IOL optic without engaging flow. Aspiration tips are placed behind the IOL optic in a dry stage starting “dry and down under.” With a standard irrigation/aspiration (I/A) tip and a 0.3 mm aspiration port, the effectual flow setting is normally kept at 20 to 25 mL per minute and the vacuum setting about 250 to 300 mm Hg, with a potential maximum setting at 500 mm Hg. Bottle height should be around 60 to 70 cm above eye level. Flow is not engaged until the I/A tip has been positioned behind the IOL optic. Thus, the tip is initially protected by the surrounding OVD, as with any surgical instrument (Figure 1). 0886-3350/00/$–see front matter PII S0886-3350(00)00420-4
TECHNIQUES: TETZ
Figure 1. (Tetz) In the first step of the 2-compartment technique, the I/A tip is placed behind the IOL optic with the IOL still slightly decentered (starting dry down under).
Figure 2. (Tetz) The I/A tip, aspiration port up, is positioned and the flow engaged. The capsular bag is emptied and the viscoadaptive OVD removed as the anterior chamber remains filled and stabilized by Healon5. The bag is inflated by the irrigation flow, and the posterior capsule is held at distance.
After the viscoadaptive OVD is completely removed from the capsular bag, which can be easily visualized because of the high refractive index of Healon5, the tip is removed from behind the optic by continuing flow and placed on top of the optic, aspiration port facing upward. The removal is continued by circling the I/A tip at the iris plane or on the optic surface, and the OVD is visualized as it is removed (Figure 3). A final sweep may be made along the anterior chamber angle to remove remaining OVD. Figure 3. (Tetz) In the second step of the 2-compartment technique, the viscoadaptive OVD is removed from the second compartment, the anterior chamber.
The flow is started only after the IOL optic rim has been arrested against the sleeve or tip’s irrigation chamber. Thus, the viscoadaptive OVD is removed from the capsular bag first while the anterior chamber remains filled and the iris stabilized by the Healon5. The I/A flow takes place within the capsular bag while the viscoadaptive OVD maintains the anterior chamber and prevents fluids from coming forward (Figure 2). The posterior capsule is held at distance by the irrigation fluid, which is continuously inflating the capsular bag and preventing the posterior capsule from coming forward. Thus, the risk of inadvertently aspirating the posterior capsule is avoided. 642
Results Using the 2-compartment technique reduced the removal time of Healon5 in our surgical setting from a
Figure 4. (Tetz) Removal time for Healon5 using the 2-compartment and rock ’n roll techniques (N ⫽ 30; 1 surgeon; partially influenced by surgeon’s learning curve).
J CATARACT REFRACT SURG—VOL 26, MAY 2000
TECHNIQUES: TETZ
Discussion
Table 1. Overview of cohesive and dispersive viscoelastic materials.
Rating and Viscolastic
Zero-Shear Viscosity (mPas)
Superviscous cohesive Healon5
7.0 M
MicroVisc Plus
4.8 M
Healon GV
2.0 M
Viscous cohesive MicroVisc
1.0 M
Allervisc Plus
500.0 K
Provisc
255.0 K
Healon
230.0 K
Biolon
215.0 K
Allervisc
200.0 K
Amvisc
100.0 K
Amvisc Plus
100.0 K
Medium viscous dispersive Viscoat
41.0 K
Cellugel
38.0 K
Vitrax
25.0 K
Low viscous dispersive Ocuvisc
4.3 K
Ocucoat
4.0 K
Hymecel
4.0 K
Adatocel
4.0 K
Visiolon
4.0 K
The use of OVDs in cataract surgery is important in ensuring a safe and controlled procedure. However, OVD-induced complications after surgery may occur. Important among these are IOP peaks during the first 24 hours postoperatively and capsular bag distention syndrome.1– 4 To minimize these complications, complete, safe, and fast removal of OVDs is required. Depending on their physical and biochemical properties, viscoelastic materials may require different removal techniques. Ophthalmic viscosurgical devices have been categorized into 2 groups: cohesive and super cohesive (e.g., Healon, Healon GV) and dispersive (e.g., Viscoat and Ocucoat威 [hydroxypropyl methylcellulose]).4 New viscoadaptive OVDs, such as Healon5, may be best removed by the 2-compartment technique. The space-maintaining capacities of Healon5 in the anterior chamber are used while the OVD is being removed from the capsular bag. In the second step, the anterior chamber is cleaned. As new OVDs are introduced, surgeons continue to adapt steps of their procedure to the new features of the substances. Although it is still impossible to completely remove some dispersive OVD from the eye, the 2-compartment technique allows fast and complete removal of viscoadaptive OVDs.
References
M ⫽ million; K ⫽ thousand
mean of 44 seconds (Figure 4) using the rock ’n roll technique to 18 seconds. The 2-compartment technique was used over 5 months in more than 250 eyes. No eye had a severe IOP spike or posterior capsule rupture. The technique can also be used to easily remove any OVD such as methylcellulose, sodium hyaluronate (Healon威), and sodium chondroitin sulfate–sodium hyaluronate (Viscoat威) because of the method’s additional advantage of having the OVD in the anterior chamber while the capsular bag is being cleaned. However, the technique works best with a viscoadaptive OVD because of its high space-maintaining capacity at low shear rates, which keeps the anterior chamber filled until the bag is free of the OVD.
1. Kohnen T, von Her M, Schu¨tte E. Postoperativer Druckverlauf in den ersten Tagen nach intraokularem Einsatz von Hyaluronsa¨urelo¨sung mit unterschiedlicher Viskosita¨t. Klin Monatsbl Augenheilkd 1995; 207:29 –36 2. Kohnen T, von Her M, Schu¨tte E, Koch DD. Evaluation of intraocular pressure with Healon and Healon GV in sutureless cataract surgery with foldable lens implantation. J Cataract Refract Surg 1996; 22:227– 237 3. Miyake K, Ota I, Ichihashi S, et al. New classification of capsular block syndrome. J Cataract Refract Surg 1998; 24:1230 –1234 ¨ bersicht. New 4. Dick B, Schwenn O. Viskoelastika; Eine U York, NY, Springer, 1998; 19,73–77 5. Assia EI, Apple DJ, Lim ES, et al. Removal of viscoelastic materials after experimental cataract surgery in vitro. J Cataract Refract Surg 1992; 18:3– 6 6. Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. J Cataract Refract Surg 1999; 25:167–173
J CATARACT REFRACT SURG—VOL 26, MAY 2000
643