EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/194331
October 2013 DisCoVisc® Ophthalmic Viscosurgical Device (Sodium Chondroitin Sulfate – Sodium Hyaluronate). Caution: Federal (USA) law restricts this device to sale by or on the order of a physician. Description: DisCoVisc® Ophthalmic Viscosurgical Device has an intermediate cohesive/dispersive index (CDI) and can best be described as the first viscous dispersive viscoelastic and is optimized for the entire surgical procedure. Indications: DisCoVisc® Ophthalmic Viscosurgical Device is indicated for use during surgery in the anterior segment of the eye. It is designed to create and maintain space, to protect the corneal endothelium and other intraocular tissues and to manipulate tissues during surgery. It may also be used to coat intraocular lenses and instruments during cataract extraction and IOL insertion. Warnings: Failure to follow assembly instructions or use of an alternate cannula may result in cannula detachment and potential patient injury. Precautions: Precautions are limited to those normally associated with the surgical procedure being performed. Although sodium hyaluronate and sodium chondroitin sulfate are highly purified biological polymers, the physician should be aware of the potential allergic risks inherent in the use of any biological material. Adverse Reactions: DisCoVisc® Ophthalmic Viscosurgical Device was very well tolerated in nonclinical and clinical studies. A transient rise in intraocular pressure in the early postoperative period may be expected due to the presence of sodium hyaluronate, which has been shown to effect such a rise. It is therefore recommended that DisCoVisc® OVD be removed from the anterior chamber by thorough irrigation and/or aspiration at the end of surgery to minimize postoperative IOP increases. Do not overfill anterior chamber. ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. U.S. Patent Nos. 5,273,056; 5,876,379 and 6,051,560. DUOVISC® Viscoelastic System is designed to give two viscoelastic materials with different physico-chemical properties that can be used differently and/or sequentially to perform specific tasks during a cataract procedure. DUOVISC® Viscoelastic System consists of VISCOAT® Ophthalmic Viscosurgical Device and PROVISC® Ophthalmic Viscosurgical Device. CAUTION: Federal law restricts this device to sale by or on the order of a physician. VISCOAT® OVD (Sodium Chondroitin Sulfate – Sodium Hyaluronate) Ophthalmic Viscosurgical Device INDICATIONS: VISCOAT® OVD is indicated for use as an ophthalmic surgical aid in anterior segment procedures including cataract extraction and intraocular lens (IOL) implantation. Viscoat maintains a deep anterior chamber during anterior segment surgeries, enhances visualization during the surgical procedure, and protects the corneal endothelium and other ocular tissues. The viscoelasticity of the solution maintains the normal position of the vitreous face and prevents formation of a flat chamber during surgery. WARNINGS: Failure to follow assembly instructions or use of an alternate cannula may result in cannula detachment and potential patient injury. PRECAUTIONS: Precautions are limited to those normally associated with the surgical procedure being performed. Although sodium hyaluronate and sodium chondroitin sulfate are highly purified biological polymers, the physician should be aware of the potential allergic risks inherent in the use of any biological material. ADVERSE REACTIONS: VISCOAT OVD has been extremely well tolerated in human and animal studies. A transient rise in intraocular pressure in the early postoperative period may be expected due to the presence of sodium hyaluronate, which has been shown to effect such a rise. It is therefore recommended that Viscoat be removed from the anterior chamber by thorough irrigation and/or aspiration at the end of surgery to minimize postoperative IOP increases. Do not overfill anterior chamber. ® ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. PROVISC® OVD (Sodium Hyaluronate) Ophthalmic Viscosurgical Device INDICATIONS: ProVisc® OVD is indicated for use as an ophthalmic surgical aid in the anterior segment during cataract extraction and intraocular lens (IOL) implantation. Ophthalmic viscoelastics serve to maintain a deep anterior chamber during anterior segment surgery allowing reduced trauma to the corneal endothelium and surrounding ocular tissues. They help push back the vitreous face and prevent formation of a flat chamber during surgery. PRECAUTIONS: Postoperative increases in intraocular pressure have been reported with sodium hyaluronate products. The IOP should be carefully monitored and appropriate therapy instituted if significant increases should occur. It is recommended that PROVISC® OVD be removed by irrigation and/or aspiration at the close of surgery. Do not overfill anterior chamber. Although sodium hyaluronate is a highly purified biological polymer, the physician should be aware of the potential allergic risks inherent in the use of any biological material; care should be used in patients with hypersensitivity to any components in this material. Cannula assembly instructions should be followed to prevent patient injury. ADVERSE REACTIONS: Postoperative inflammatory reactions such as hypopyon and iritis have been reported with the use of ophthalmic viscoelastics, as well as incidents of corneal edema, corneal decompensation, and a transient rise in intraocular pressure. ATTENTION: Reference the Physician Labeling/Directions for Use for a complete listing of indications, warnings and precautions. © 2013 Novartis 9/13 VIS13035JAD-PI Chopped continued from page 96 can first engage a small heminucleus with high vacuum and maneuver it to the center of the eye such that the endonuclear equator is central to the anterior capsule edge. This then allows for placement of the chopper safely at the edge of the nucleus without the need to maneuver under the anterior capsular margin. However, in cases of large heminuclei or in horizontal quick chop, this approach is not an option. After aspiration of the central cortex and epinucleus, the first step is that the chopper should contact the anterior surface of the CENTER of the endonucleus, well within the boundaries of the capsulorhexis. If the chopper is touching the endonucleus centrally, it cannot be above the anterior capsule, assuming the lens has not been prolapsed into the sulcus. Then while maintaining contact with the anterior surface of the endonucleus, the chopper is dragged peripherally until the equatorial edge of the endonucleus is reached. Although it is tempting to use the visual feedback of the hydrodelineation ring to determine the equatorial edge, this can be dangerous without maintaining contact with the nuclear surface. There should be a tactile sense that one has reached the edge of the endonucleus since there should be contact with its anterior surface throughout this maneuver. The sensation is similar to skating one's fingertips across a tabletop until the edge of the table is reached and the fingers drop around the edge of the table. If residents maintain this tactile contact with the endonucleus as they radially skate the chopper toward the endonuclear edge, they cannot go over the anterior capsule, thus avoiding the complication in this case. Once an iatrogenic zonular dialysis is identified, the first step is to tamponade the area by filling the capsular bag with viscoelastic. The presence or absence of vitreous can then be ascertained with the use of triamcinolone acetonide. In most cases like this, vitreous will not be present in the anterior chamber since the anterior hyaloid has not been violated. If no vitreous is noted, we use capsular retraction hooks to secure the bag while the remainder of the cataract, including cortical material, is removed. This is the ideal indication for use of a CTR since there is limited traumatic zonular dialysis. The CTR enables the surgeon to distribute the stability of the intact zonules to the area of zonular weakness. Figure 2: CTR placed to support stressed area of zonules Figure 3: IOL is nicely centered with CTR despite zonule damage Source (all): Thomas Oetting, MD Susan M. MacDonald, MD Lahey Clinic Assistant professor, Tufts School of Medicine Boston An unfortunate thing about being human is we are less than perfect; as a result we make mistakes. In this particular case it appears that there was a miscalculation of the location of the horizontal chopper, a mere 20-micron distance. The resident believed the instrument was under the capsule and proceeded to maneuver the chopper into position, out to the nucleus equator, to chop the cataract. Since the instrument was in front of the capsule, the maneuver resulted in zonular breakage and ultimately zonular dehiscence of the capsular bag. This is a fine example of one type of human error, our vision. What we see is a combination of our sight plus what we think we are seeing, and sometimes, it is inaccurate. A few modifications can make this less likely to happen. First improve visibility and enhance it. This can be done by capsule staining with trypan blue. Once the capsule is more distinct it is important to have meticulous focus throughout the case. This means taking time to refocus. The focus can be affected by changes in the patient's head position and the sturdiness of the chair/ bed's headpiece to resist movement when the surgeon's hands are leaning on it or the surgeon's knees push up on it. Second, make a larger than usual capsulorhexis. This increase of 1-1.5 mm will increase the safety by