Eyeworld

51 EW FEATURE I N S T R U M E N T S | S I N G L E U S E | D R Y E Y E | B I O L O G I C S © 2018 Stephens Instruments. All rights reserved. Stephens Instruments | 2500 Sandersville Rd | Lexington KY 40511 USA Toll Free ( USA ) 800.354.7848 | info@stephensinst.com | stephensinst.com SAVE TIME & MONEY Removes hidden costs of time and resources spent on cleaning, sterilization, repair and replacement. REDUCE RISK Reduces risk of cross contamination. Overall improved patient safety. FRESH & PRECISE Each procedure begins with a new, precise and sterile SafeSite™ instrument. ! Look to Stephens for single-use instruments. SafeSite ™ Sterile Single-Use Instruments $ The other role is on the cornea when putting in the gonioscopy lens, Dr. Noecker said, because it helps with the view of the angle and you'll be less likely to get air bubbles. The key with the iStent/iStent inject, Dr. Noecker said, is that you have to be able to visualize the trabecular meshwork and Schlemm's canal. Dr. Noecker said using viscoelas- tic with other surgeries, such as with the OMNI and iTrack (Ellex) devices, can be helpful. In these canal-based procedures, viscoelastic is used for visualization and as a therapeutic device to visco-dilate the canal. Dr. Noecker noted that it may also be useful in endoscopic cyclo- photocoagulation (ECP). Viscoelas- tic can be used for visualization to protect the iris, he said. Additional thoughts Dr. Noecker said that viscoelastic can also be a tool to minimize the use of sutures. If someone has hy- potony, viscoelastic can be injected postoperatively in the office. If the anterior chamber of the eye is shallow, surgeons can use viscoelas- tic and inject it in the pre-existing paracentesis site, or they can inject viscoelastic with a needle into the AC to pressurize the eye and protect it. "I think viscoelastics are a key point of both traditional and MIGS surgeries," Dr. Noecker said. It's something he uses on every single case because it can help make the case safer and easier to visualize. "I think we can use it as a tool to minimize the chance of having low pressure during the surgery, as well as postoperatively," he said. EW Editors' note: Dr. Noecker has finan- cial interests with Allergan (Dublin, Ireland), Alcon, and Ellex. Dr. Brubak- er has financial interests with Alcon, Allergan, and New World Medical. Dr. Radcliffe has financial interests with Alcon, Allergan, Ellex, New World Medical, and Sight Sciences. Contact information Brubaker: jacobbrubaker@me.com Noecker: noeckerrj@gmail.com Radcliffe: drradcliffe@gmail.com MIGS and the use of OVDs In MIGS, viscoelastic is put in when performing gonio surgery, Dr. Rad- cliffe said. He added that leaving a little behind can be helpful to prevent hyphema. In longer MIGS procedures, Dr. Radcliffe said, it can help to use a more robust cohesive, like Healon 5 or Healon GV (John- son & Johnson Vision), that will keep the chamber deeper for longer to achieve the surgery. These do a good job maintaining the chamber, he said, but they don't stop bleeding as well, so you may need to use Vis- coat or a dispersive to stop bleeding on the angles. Dr. Radcliffe added that Viscoat can help prevent bleed- ing after MIGS surgery. He explained that in some cases, for example a patient undergoing trabecular meshwork surgery who is on a blood thinner, he will coat the trabecular meshwork with the dispersive OVD Viscoat prior to filling the rest of the anterior chamber with a cohesive viscoelastic because the dispersive is more effective at tamponading the blood while the cohesive OVD keeps the chamber deep. Dr. Brubaker said most viscoelas- tics have predominantly been used in the past to maintain the chamber, and you can use different viscoelas- tics based on how deep you want your chamber and the stability you need. The big change more recently is using it as a therapeutic treatment as opposed to a temporary mainte- nance of the chamber. ABiC (Ellex, Adelaide, Australia), GATT with visco-dilation, and the OMNI Glaucoma Treatment System (Sight Sciences, Menlo Park, Cali- fornia) predominately use cohesive viscoelastic, he said, noting that he uses Healon GV, which has the highest cohesive properties of all the viscoelastics. When doing MIGS procedures, like the iStent or iStent inject (Glau- kos, San Clemente, California), Dr. Noecker said it's key to have good visualization of the angle. Since this is often done in conjunction with cataract surgery, he likes to put the devices in after the completion of cataract surgery. "I usually use Viscoat because I've already used this with cataract surgery," he said. It helps to inflate the angle and get good visualization, Dr. Noecker added. Pressurizing the eye with vis- coelastic will help minimize blood reflex from Schlemm's canal.

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