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As these OVDs can have different flow rates, they can also offer protection for structures, such as the corneal endothelium [ 8 , 27 ]. The objective of these dual viscoelastic systems is to obtain long-lasting protection of the intraocular structures and corneal endothelium dispersive characteristics , but also to facilitate the capsulorhexis and IOL implantation as well as its removal at the end of the surgery cohesive characteristics [ 7 , 29 ].
A current example of a DuoVisc system that combines Viscoat dispersive and ProVisc cohesive is Twinvisc from Carl Zeiss Meditec a combination of a dispersive and a cohesive OVD, both comprising sodium hyaluronate, in a single syringe separated by a bypass stopper system or the combination of Healon D with Healon or Healon GV [ 7 , 18 , 30 ].
Arshinoff in [ 31 ]. With this technique, two viscoelastic agents are used simultaneously. First, the dispersive OVD is injected into the eye and the endothelium is coated. Afterwards, the cohesive OVD is injected underneath to smooth the anterior lens capsule and deepen the anterior chamber as well as to push the dispersive OVD further towards the endothelium [ 31 ]. If the zonula is weak, the dispersive OVD can divide the eye and push the vitreous body backwards, while the cohesive OVD forms the anterior chamber and keeps it under pressure [ 31 ].
Several OVD types can be used for different purposes and at different stages during surgery. For example, the use of a cohesive OVD can help to enlarge a small and unresponsive pupil, to smooth the front capsule [ 17 , 20 , 21 , 22 , 23 ], and to create space by deepening the anterior chamber, whereas a dispersive OVD is the best option to protect the corneal endothelium over a longer period [ 8 , 19 , 21 , 22 , 24 ].
A dispersive OVD is also needed when preparing an IOL, lubricating a cartridge, or folding a lens, but it is more difficult to be removed from the eye and more likely to increase the IOP [ 16 , 18 , 23 , 24 , 26 ].
For these reasons, there are also systems containing both types of OVD, cohesive and dispersive, as previously mentioned [ 7 , 18 , 29 , 30 ].
Likewise, there are specific surgical strategies, such as the soft-shell technique [ 31 ], which use both OVD types in layers on top of each other. The goal of all these approaches is always to combine the advantages of cohesive and dispersive substances.
The selection of the appropriate OVDs is especially crucial in complex or challenging cases, such as in hard cataracts [ 11 , 32 ], flat anterior chambers [ 12 ], narrow pupils and the pseudoexfoliation syndrome [ 33 ], intraoperative floppy iris syndrome [ 34 ], disinserted zonular fibers [ 34 ], Fuchs endothelial dystrophy [ 34 ], small holes in the posterior capsule with protruding vitreous [ 34 ], and hypotonic eyes due to previous glaucoma surgeries [ 35 ].
Indeed, the type of OVDs used in such cases may determine the success of the surgery, the postoperative outcome, and consequently the overall patient satisfaction. For this reason, it is important to know the OVDs commercially available and to understand their properties, leading to different advantages and disadvantages. Cataract surgery in eyes with hard brown cataract or Brunescent and Morgagnian cataracts remains a challenge for eye surgeons because of the higher risk of complications, such as nucleus drop, posterior capsule rupture, corneal burn, and corneal endothelial damage [ 11 , 32 ].
Of particular relevance are the potential effects of the longer surgical maneuvers and the higher levels of ultrasound energy commonly used in these cases on the corneal endothelium [ 36 , 37 ].
For this reason, the use of dispersive OVDs seems to be an adequate option to achieve an optimal endothelial protective effect [ 32 ], although the use of combined agents may be adequate to facilitate also some surgical steps [ 38 ].
Toprak and Yaylali [ 11 ] described in two maneuvers to be used in different steps of phacoemulsification surgery in hard cataracts, providing debulking of the central dense nucleus and preventing posterior capsule rupture.
These authors recommended the use of a cohesive OVD to fill the anterior chamber and to protect the corneal endothelium. Likewise, the OVD was used to inflate the capsular bag before IOL insertion, retreating the posterior capsule backward and safety preventing the rupture of this thin layer [ 11 ]. Yuan et al. Specifically, the authors described a technique in which, after dislocation of the nucleus into the anterior chamber and OVD injection to protect the corneal endothelium and expand the capsular bag, the OVD cannula was passed beneath the nucleus, where more OVD was injected to promote its lifting.
Subsequently, some pressure was applied to the posterior lip of the tunnel incision by the angle of the OVD needle, which allowed smooth extraction of the nucleus with the efflux of the OVD [ 32 ].
Moreover, it has been shown that viscodissection rather than hydrodissection in cases with very loose zonules e. The pseudoexfoliation syndrome PSX is a complex age-related disorder characterized by the progressive accumulation of abnormal extracellular pseudoexfoliative material in ocular tissues, including the ciliary body, iris, iridocorneal angle, and lens capsule [ 40 ].
This may complicate the performance of cataract surgery due to pupillary abnormalities generated by this condition, such as significant miosis and a limitation of the dynamic pupillary pattern [ 40 ]. Indeed, iris hooks or Malyugin rings are sometimes needed for a mechanical pupil dilation allowing the surgeon to have an adequate visualization of the anterior segment [ 41 ].
A new tool to facilitate the surgical procedure in eyes with PSX and not reacting pupils is the use of an OVD combined with a staining agent [ 33 ]. It is available in a prefilled syringe to allow for the simultaneous administration of the OVD and staining agent in one single step [ 33 ].
The aim of this blue-colored OVD is to deepen the anterior chamber, to protect the corneal endothelium, and simultaneously to stain the capsule, facilitating the creation of the continuous curvilinear capsulorhexis and surgery, and consequently minimizing the time needed for the procedure. A recent comparative case series has demonstrated that the use of this blue-colored OVD in PSX eyes with not reacting pupils can provide a statistically significant time gain in terms of surgery duration compared to the use of a standard clear OVD, with additional potential benefits in surgeon satisfaction, postoperative corrected distance visual acuity and IOP, as blue OVD remnants can be identified and removed more easily [ 33 ].
In , Chang and Campbell first described the intraoperative floppy iris syndrome IFIS in patients with benign prostatic hyperplasia and systemic administration of alpha-A1 adrenoceptor antagonist tamsulosin [ 42 ].
This condition is characterized by a loss of the iris muscle tone leading to significant pupil constriction despite pupil dilatation with standard mydriatic drugs before the initiation of cataract surgery. IFIS can lead to an increased complication rate in this type of eye surgery due to fluttering and billowing of the iris stroma caused by ordinary intraocular fluid flows, a marked tendency for the iris to prolapse toward the side port incisions, and progressive constriction of the pupil during surgery [ 43 ].
All these signs are accompanied by suboptimal pupillary dilation in response to preoperative mydriatic protocols [ 42 ]. In addition, pupillary stretching techniques are ineffective because of the floppy, easily stretched nature of the pupil margin [ 42 , 44 ]. Since incision leakage through the clear-cornea incisions can further promote the IFIS effect, tight incisions and longer tunnels are essential in these cases when performing cataract surgery [ 44 ].
Chang recommended the use of iris hooks or other mechanical devices intraoperatively for pupillary dilation, such as the Malyugin ring [ 45 ].
However, a failure to detect IFIS before the performance of the capsulorhexis might make the use of these instruments more difficult [ 45 ]. Steve A. As previously mentioned, the soft-shell technique consists of using two viscoelastic agents simultaneously to achieve a better iris stabilization during the entire procedure [ 31 ]. Afterwards, a cohesive OVD is injected onto the surface of the anterior lens capsule in the middle of the anterior chamber, maintaining the boundary between the cohesive and dispersive OVD at the pupil edge.
The USST is a modification of the soft-shell technique consisting of compartmentalizing the anterior chamber using low-viscosity fluids, such as balanced salt solution or trypan blue, in combination with a viscoadaptive OVD, such as Healon 5 sodium hyaluronate 2. The use of this technique facilitates the surgical procedure owing to the effect of the viscoadaptive OVD and OVD removal at the end of the procedure [ 46 ].
In , a combination variant of the soft-shell technique and USST was described, in which the flow parameters were adjusted [ 47 ]. The TST approach is a generalization of all these previously described soft-shell concepts [ 34 ]. After this, a cohesive or viscoadaptive OVD is injected beneath the dispersive OVD onto the anterior capsule, displacing the dispersive OVD upward against the endothelial surface of the cornea.
The injection of the second OVD is continued until the pupil stops dilating and before the eye becomes firm. With these maneuvers, a low-viscosity protective outer dispersive OVD shell is generated that encircles a cohesive or a viscoadaptive OVD pressurizing and stabilizing the inner shell previously created. Injection of balanced salt solution or lidocaine-phenylephrine is then performed slowly beneath the viscoadaptive OVD to create a continuous low-viscosity fluid on the lenticular surface, with the pupillary margin as the peripheral border.
Consequently, the viscoadaptive shell is displaced upwards acting as a central bridge [ 34 ]. With this procedure, maximum control over the operative environment is achieved in IFIS eyes, minimizing the incidence of complications [ 34 ]. Local anesthetic agents block the conduction of nerve impulses by acting directly on voltage-gated sodium channels.
Intracameral injection of lidocaine affects all nerve fibers in the anterior chamber to some degree, causing anesthesia and akinesia of the iris. The intracameral anesthesia effect and OVD function maintenance of the anatomical space and protection of surrounding tissues were also combined in one single step [ 50 , 51 , 52 , 53 ].
This type of system may provide more comfort to patients, making the application of the anesthetic easy [ 50 ]. In fact, there is some scientific evidence of the superiority of the use of VisThesia compared to the conventional procedure in terms of intraoperative pain [ 50 ]. Some colleagues have reported a greater increase in macular thickness with the use of VisThesia [ 50 ] as well as a greater reduction of corneal endothelial cell density compared to the use of conventional OVDs [ 50 , 51 ].
But results are contradictory with some other authors that showed no greater reduction of endothelial cell count with the use of VisThesia [ 52 ].
More research is still needed to confirm the potential benefits and risks of the use of viscoanesthesia in cataract surgery as well as the most appropriate indications for this modality of OVD. The formation of a significantly flat anterior chamber is a complication associated with eyes that have had previous glaucoma surgery [ 54 ].
The persistence of a flat anterior chamber in the eye can cause further complications, such as peripheral anterior synechiae or endothelial dysfunction [ 54 ]. For this reason, this condition must be treated, for which various pharmacologic atropine, phenylephrine, and in selected cases orally administered acetazolamide and surgical options are available [ 55 , 56 ].
One of these options is the injection of OVD into the anterior chamber, first described in by Fisher et al. Some years later, the successful use of a viscoadaptive OVD Healon 5 to treat a flat anterior chamber after trabeculectomy was reported [ 58 ], as well as the application of dispersive OVDs [ 12 ].
However, the long-term success rate with OVD injection in these cases has been demonstrated to be relatively low [ 12 ]. For this reason, combinations of OVD with other stabilizing substances have been tested, such as the combination of Healon and sulfur hexafluoride [ 59 ].
In this relatively new field OVD is used for protection of corneal endothelium during posterior lamellar graft preparation and viscodissection. OVDs in cataract surgery protect ocular structures from mechanical trauma, divide tissue, create space, resolve adhesions, act as a wetting agent, or as an instrument to facilitate the surgical procedure.
OVDs can be classified as cohesive, dispersive, or viscoadaptive according to the level of viscosity and cohesion. There are also systems combining different OVDs or combining an OVD with other substances anesthetic, trypan blue that are commonly used for the most challenging cases to minimize the complication rate. The use of dispersive OVDs or combined agents seems to be the most optimal option to ensure adequate corneal endothelial protection in cases of hard cataract.
Specifically, the soft-shell technique sequential injection of a dispersive and a cohesive OVD has been shown to be useful in eyes with a hard lens nucleus with and without Fuchs dystrophy. Finally, the potential beneficial effect on the control of intraoperative pain with injection of a combination of OVD and lidocaine was also investigated, showing good results regarding the degree of pain control achieved.
Good knowledge of all OVD types is mandatory for the ophthalmic surgeon to achieve the best results. Hyaluronic acid in orthopedics.
Wiad Lek. PubMed Google Scholar. Balazs EA. Physical chemistry of hyaluronic acid. Fed Proc. Higashide T, Sugiyama K. Use of viscoelastic substance in ophthalmic surgery—focus on sodium hyaluronate. Clin Ophthalmol. Healon, Healon GV, Healon5 products sodium hyaluronate ophthalmic viscoelastic devices. Regulation number: Arshinoff SA, Hofmann I. Prospective, randomized trial of Microvisc and Healon in routine phacoemulsification.
J Cataract Refract Surg. Methylcellulose and lens implantation. Br J Ophthalmol. Impact of ophthalmic viscosurgical devices in cataract surgery. J Ophthalmol. The protective effect of ophthalmic viscoelastic devices on endothelial cell loss during cataract surgery: a meta-analysis using mixed treatment comparisons. Arshinoff SA, Jafari M.
New classification of ophthalmic viscosurgical devices Rheological and adhesive properties to identify cohesive and dispersive ophthalmic viscosurgical devices. Chem Pharm Bull. CAS Google Scholar. Toprak I, Yaylali V. Case Rep Med. Ophthalmic viscoelastic device injection for the treatment of flat anterior chamber after trabeculectomy: a case series study. Hyaluronan as an ophthalmic viscoelastic device. Curr Pharm Biotechnol. Efficacy of ophthalmic viscosurgical devices in maintaining corneal epithelial hydration and clarity: in vitro assessment.
Epiretinal deposits post cataract extraction. Retin Cases Brief Rep. Arshinoff SA, Wong E. Understanding, retaining, and removing dispersive and pseudodispersive ophthalmic viscosurgical devices. Evaluation of rheological properties of cohesive ophthalmic viscosurgical devices composed of sodium hyaluronate with high molecular weight. Yakugaku Zasshi. Comparison of the performance and safety of 2 ophthalmic viscosurgical devices in cataract surgery. Comparison of the corneal endothelial protective effects of Healon-D and Viscoat.
Clin Experiment Ophthalmol. Google Scholar. Bissen-Miyajima H. In vitro behavior of ophthalmic viscosurgical devices during phacoemulsification. Influence of viscoelastic substances used in cataract surgery on corneal metabolism and endothelial morphology: comparison of Healon and Viscoat. Effect of Healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery.
Removal times for a dispersive and a cohesive ophthalmic viscosurgical device correlated with intraocular lens material. Dispersive viscosurgical devices demonstrate greater efficacy in protecting corneal endothelium in vitro. BMJ Open Ophthalmol.
Corneal endothelial cell coating during phacoemulsification using a new dispersive hyaluronic acid ophthalmic viscosurgical device. Retention and removal of a new viscous dispersive ophthalmic viscosurgical device during cataract surgery in animal eyes. Survey of ophthalmic viscosurgical devices. Curr Opin Ophthalmol. Safety, efficacy, and intraoperative characteristics of DisCoVisc and Healon ophthalmic viscosurgical devices for cataract surgery.
Mixed polymeric systems: new ophthalmic viscosurgical device created by mixing commercially available devices. Comparison of the effect of Viscoat and DuoVisc on postoperative intraocular pressure after small-incision cataract surgery.
Arshinoff SA. Dispersive-cohesive viscoelastic soft shell technique. Ophthalmic viscosurgical device-assisted sutureless-incision cataract surgery for a hard nucleus or mature cataract. Evaluation of a novel blue-colored ophthalmic viscoelastic device applied during phacoemulsification in eyes with pseudoexfoliation syndrome. Case Rep Ophthalmol. Arshinoff SA, Norman R. Tri-soft shell technique. Case Rep Ophthalmol Med. Microincision versus small-incision coaxial cataract surgery using different power modes for hard nuclear cataract.
Torsional ultrasound mode versus combined torsional and conventional ultrasound mode phacoemulsification for eyes with hard cataract. Efficacy and safety of the soft-shell technique in cases with a hard lens nucleus. Considering the amount of viscoelastic material used during phacoemulsification, a significantly larger quantity of 2.
In addition, Praveen et al. Our study did not include eyes with dense sclerosis, as dense cataract emulsification is cited as a risk factor for excessive cell loss 22, Furthermore, there were no statistically differences between the two OVD groups in terms of cataract density, ultrasound time or CDE Table 1 , thus eliminating any potential effects of these variables. The fact that this study utilized a contralateral comparison minimized intra-individual factors that could have interfered with the outcomes.
However, one limitation of this study was that only simple cataract cases were included. One previous study 24 evaluating DisCoVisc in complex ocular environments showed that this OVD facilitated good intraoperative performance in complex cases and was effective in simple cataract surgeries; however, this study was observational and non-comparative.
In conclusion, the viscous, dispersive OVD DisCoVisc was more efficient during phacoemulsification and was able to be more rapidly removed after IOL implantation compared to 2. The degree of corneal endothelial cell loss was also significantly lower with DisCoVisc than with 2.
The authors report no financial support. The authors also report no proprietary or commercial interest in any of the materials discussed in this article.. Castro EF designed and conducted the study, and was also responsible for the data collection and interpretation, and review of the manuscript. Santhiago MR managed the study and was also responsible for the data interpretation and review of the manuscript.
Kara-Junior N designed, conducted and managed the study and was also responsible for the review of the manuscript. All authors participated sufficiently in this work to take public responsibility for appropriate portions of the content..
Previous article Next article. Issue 9. Pages January Export reference. More article options. DOI: Download PDF. Rodrigo F. Corresponding author. This item has received. Under a Creative Commons license. Article information. METHODS: This prospective, randomized clinical trial comprised 78 eyes 39 patients that received phacoemulsification performed by the same surgeon using a standardized technique.
Full Text. For the primary outcome measures, the statistical tests were conducted at a level of p RESULTS Seventy-eight eyes from 39 consecutive patients 13 men [ Table 1. Intraoperative variables. DisCoVisc 2. Table 2. The authors also report no proprietary or commercial interest in any of the materials discussed in this article. Corneal endothelial cell protection during phacoemulsification; low versus high molecular weight sodium hyaluronate.
J Cataract Refract Surg, 28 , pp. Intraocular pressure after small incision cataract surgery with Healon5 and Viscoat. J Cataract Refract Surg, 26 , pp. New classification of ophthalmic viscosurgical devices - J Cataract Refract Surg, 31 , pp. Transient corneal edema after phacoemulsification: comparison of 3 viscoelastic regimens. Phacoemulsification versus extracapsular extraction: governmental costs.
Clinics, 65 , pp. Corneal thickness and visual acuity after phacoemulsification with 3 viscoelastic materials. Dispersive and cohesive viscoelastic materials in phacoemulsification. Ophthalmic Pract, 13 , pp. Ophthalmology, , pp. In vitro behavior of ophthalmic viscosurgical devices during phacoemulsification.
J Cataract Refract Surg, 32 , pp. DisCoVisc versus the soft-shell technique using Viscoat and Provisc in phacoemulsification: randomized clinical trial. J Cataract Refract Surg, 34 , pp. Prospective randomized comparison of DisCoVisc and Healon5 in phacoemulsification and intraocular lens implantation, 24 , pp.
Prospective randomized trial comparazing DisCoVisc versus Healon5 in phacoemulsification. Arch Soc Esp Oftalmol, 82 , pp. Same-day versus first-day review of intraocular pressure after uneventful phacoemulsification.
J Cataract Refract Surg, 29 , pp. Clinical results of phacoemulsification with the use of Healon5 or Viscoat. J Cataract Refract Surg, 27 , pp. Effect of Healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery.
Intraocular pressure rise after small incision cataract surgery: a randomised intraindividual comparison of two dispersive viscoelastic agents. Br J Ophthalmol, 85 , pp. Surv Ophthalmol, 34 , pp. Retention and removal of a new viscous dispersive ophthalmic viscosurgical device during cataract surgery in animal eyes. The British journal of ophthalmology, 90 , pp. Risk factors for corneal endothelial injury during phacoemulsification.
J Cataract Refract Surg, 22 , pp. Effect of cataract surgery on the corneal endothelium; modern phacoemulsification compared with extracapsular cataract surgery. Subjective evaluation of intraoperative performance of DisCoVisc in complex ocular environments. Eye Lond , 24 , pp. No potential conflict of interest was reported. All authors participated sufficiently in this work to take public responsibility for appropriate portions of the content.
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