In some surgical cases, we need more than the standard 0.55 mL of viscoelastic. For example, additional viscoelastic is particularly helpful in cases of intraoperative aberrometry because we’re trying to achieve a physiologic pressure that ensures that we get accurate readings. More viscoelastic is also helpful in minimally invasive glaucoma surgery (MIGS) cases. After removing the cataract, it is important to have a nice open anterior chamber so we can easily visualize the angle and implant the MIGS device.
Now, instead of opening two syringes of viscoelastic for cases like these, I use the DUOVISC XL (Alcon) ophthalmic viscosurgical device (OVD), a packaged pair of VISCOAT OVD with a 0.85 mL syringe of PROVISC OVD. This has been a welcome addition to my OR. It removes the decision of whether to open a second syringe of viscoelastic or try to get by with one, knowing that will not be ideal. DUOVISC XL OVD allows me to always use a single syringe to optimally pressurize the eye for intraoperative aberrometry, angular surgeries, and any other visualization needs.
Case Details
During a case in which a high myopic patient underwent cataract surgery with a premium multifocal IOL (I used the Alcon ACRYSOF IQ RESTOR IOL with ACTIVEFOCUS optical design), I wanted to ensure I had enough viscoelastic to do intraoperative aberrometry measurement with ease. I ordered DUOVISC XL OVD for the case.
I used topical intracameral lidocaine and made a paracentesis. Next, I completed the capsulotomy using my capsulotomy forceps (MST), which have hash marks that show the diameter and allow me to manually create a nice round capsulotomy very easily. (We employ laser and precision pulse capsulotomy in some cases as well.) I take a divide-and-conquer approach to most cataracts, and this case was no exception. I used the Connor wand as my second instrument, achieving a decent crack and then spinning the lens in each quadrant to ensure that it was free from cortical attachments to the lens fiber. Hydrodissection was achieved easily in this case. Using the soft, gentle polymer tip of the INTREPID Transformer I/A Handpiece (Alcon), I polished aggressively the posterior capsule, and all the cortical material came out nicely.
Figure. John P. Berdahl, MD, uses VISCOAT OVD at the beginning of surgery.
To achieve the target intraocular pressure for this high myope, I filled the anterior chamber and the capsular bag with the PROVISC viscoelastic, making sure there were no folds or bubbles. I used about 0.65 mL of the viscoelastic, leaving some in the injector as a nice safety blanket in case I needed more as I put in the lens.
At this point, I performed intraoperative aberrometry. Usually, when I make these measurements for a toric or a multifocal IOL on a “virgin eye” (with no previous surgery), I only take one measurement. If that measurement verifies my preoperative plan, then I align the toric lens based on the dynamic reticle, and I do not take a pseudophakic measurement.
However, if the eye has had previous LASIK, or if the first aberrometry measurement doesn’t coincide with my preoperative plan, I will get at least three intraoperative measurements. If I capture very repeatable intraoperative aberrometry measurements, I go with them. If they are inconsistent, I hedge my bets between my preoperative plan and the intraoperative aberrometry.
In this case, intraoperative aberrometry did call for a small 0.50 D change to the lens power, so my technicians obtained, prepared, and folded the new lens and readied it for injection into the eye. Through a 2.4-mm incision, I inserted the RESTOR +2.5 D IOL with ACTIVEFOCUS optical design. I have been very happy with the results for this lens. My patients have very good contrast sensitivity, excellent distance vision, and I like the rotational stability in the toric version.1 Always keep in mind that if you are going to take pseudophakic measurements with intraoperative aberrometry, it is very important to let the lens unfold completely. Some lenses take longer to unfold. If it does not unfold completely, the toricity measurements may be unreliable. I try to remove all the viscoelastic from behind the lens as well.
Once the lens was centered, I confirmed that we achieved the desired postoperative pressure and then hydrated the wounds. I used a small amount of intraocular combination dexamethasone/moxifloxacin/ketorolac (Dex-Moxi-Ketor, Imprimis). I also injected the combination medication subconjunctivally and administered a drop of povidone-iodine. Next, I rinsed out the povidone-iodine, and the surgery was complete.
This was a straightforward case and having more viscoelastic readily available than during previous cases made it easy to achieve better visualization and pressurization. Intraoperative aberrometry was accurate. Postoperative day 1, the patient had a clear cornea with 20/20-1 vision and near acuity of J4. The procedure was more efficient as well because I didn’t have to determine whether I wanted to open a second syringe of viscoelastic during the case.
Intraoperative Aberrometry
During the past 5 to 8 years, surgical preparation and cataract surgery in general have become more complicated. Next-generation phacoemulsification technologies allow us to break up the nucleus very quickly. Specifically, the CENTURION Vision System (Alcon) offers great fluidics and ultrasound control, in addition to a very stable anterior chamber.2,3
However, we are now taking many new steps to make cataract surgery absolutely elite and precise, nailing top refractive outcomes for all of our cataract patients. For example, to perform state-of-the-art cataract surgery, we take multiple topographic measurements. During surgery, we may use a precision pulse or femtosecond laser. We use intraoperative alignment and diagnostic tools, such as image-guided toric lens alignment and intraoperative aberrometry.
I have been a big fan of intraoperative aberrometry, in part because it actually measures the posterior corneal astigmatism as part of the total astigmatism in the eye after the lens is removed.4 Other devices can measure posterior corneal astigmatism, but none of them do it after an incision is created to include surgically induced astigmatism.
It is fair to question if intraoperative aberrometry represents the postoperative state of the eye, but in my experience, those measurements certainly help me tighten up those precise outcomes and remove the outliers who would be quite unhappy with a 1.00 or 1.50 D miss. The high-volume PROVISC viscoelastic in the DUOVISC XL OVD package helps me ensure that the aberrometry is accurate and surgical outcomes meet our very high expectations.
1. AcrySof IQ ReSTOR +2.5 D IOL Directions for Use.
2. Chen M, Anderson E, Hill G, et al. Comparison of cumulative dissipated energy between the Infiniti and Centurion phacoemulsification systems. Clinical Ophthalmology. 2015;9:1367-1372.
3. Nicoli CM, Dimalanta R, Miller, KM. Experimental anterior chamber maintenance in active versus passive phacoemulsification fluidics systems. J Cataract Refract Surg. 2016; 42:157-162.
4. Alcon Data on File.
AcrySof, ACTIVEFOCUS, CENTURION, DuoVisc XL, INTREPID, ProVisc, ReSTOR, and VISCOAT are trademarks of Novartis. All other product/brand names are trademarks of their respective owners.
©2019 Novartis 2/19 US-VIS-18-E-2588a
DUOVISC® OVD Important Product Information
Description:DUOVISC® Viscoelastic System is designed to provide 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 (USA) law restricts this device to sale by, or on the order of, a physician.
Description: VISCOAT® (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® OVD 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/Precautions: Failure to follow assembly instructions or use of an alternate cannula may result in cannula detachment and potential patient injury. 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 affect such a rise. It is therefore recommended that VISCOAT® 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: Please refer to the Directions for Use for a complete listing of indications, warnings and precautions.
Description: PROVISC® (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.
Warnings/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: Please refer to the directions for use for a complete listing of indications, warnings and precautions.
CENTURION® Vision System Important Product Information
Caution: Federal (USA) law restricts this device to sale by, or on the order of, a physician.
As part of a properly maintained surgical environment, it is recommended that a backup IOL injector be made available in the event the AutoSert® IOL Injector Handpiece does not perform as expected.
Indication: The CENTURION® Vision system is indicated for emulsification, separation, irrigation, and aspiration of cataracts, residual cortical material and lens epithelial cells, vitreous aspiration and cutting associated with anterior vitrectomy, bipolar coagulation, and intraocular lens injection. The AutoSert® IOL Injector Handpiece is intended to deliver qualified AcrySof® intraocular lenses into the eye following cataract removal.
The AutoSert® IOL Injector Handpiece achieves the functionality of injection of intraocular lenses. The AutoSert® IOL Injector Handpiece is indicated for use with the AcrySof® lenses SN6OWF, SN6AD1, SN6AT3 through SN6AT9, as well as approved AcrySof® lenses that are specifically indicated for use with this inserter, as indicated in the approved labeling of those lenses.
Warnings: Appropriate use of CENTURION® Vision System parameters and accessories is important for successful procedures. Use of low vacuum limits, low flow rates, low bottle heights, high power settings, extended power usage, power usage during occlusion conditions (beeping tones), failure to sufficiently aspirate viscoelastic prior to using power, excessively tight incisions, and combinations of the above actions may result in significant temperature increases at incision site and inside the eye, and lead to severe thermal eye tissue damage.
Good clinical practice dictates the testing for adequate irrigation and aspiration flow prior to entering the eye. Ensure that tubings are not occluded or pinched during any phase of operation.
The consumables used in conjunction with ALCON® instrument products constitute a complete surgical system. Use of consumables and handpieces other than those manufactured by Alcon may affect system performance and create potential hazards.
AEs/Complications: Inadvertent actuation of Prime or Tune while a handpiece is in the eye can create a hazardous condition that may result in patient injury. During any ultrasonic procedure, metal particles may result from inadvertent touching of the ultrasonic tip with a second instrument. Another potential source of metal particles resulting from any ultrasonic handpiece may be the result of ultrasonic energy causing micro abrasion of the ultrasonic tip.
ATTENTION: Refer to the Directions for Use for the accessories/consumables and Operator’s Manual for a complete listing of indications, warnings, cautions and notes.
AcrySof® Family of Single-Piece IOLs Important Product Information
(AcrySof® UV, AcrySof ®IQ, AcrySof® IQ Toric, AcrySof®IQ ReSTOR®, and AcrySof® IQ ReSTOR® Toric IOLs)
CAUTION: Federal law restricts these devices to sale by or on the order of a physician.
INDICATION: The family of AcrySof® single-piece intraocular lenses (IOLs) includes AcrySof® UV-absorbing IOLs (“AcrySof® UV”), AcrySof ®IQ, AcrySof ®IQ Toric® and AcrySof IQ ReSTOR® and AcrySof® IQ ReSTOR® Toric IOLs. Each of these IOLs is indicated for visual correction of aphakia in adult patients following cataract surgery. In addition, the AcrySof Toric IOLs are indicated to correct pre-existing corneal astigmatism at the time of cataract surgery. The AcrySof IQ ReSTOR IOLs are for cataract patients with or without presbyopia, who desire increased spectacle independence with a multifocal vision. All of these IOLs are intended for placement in the capsular bag.
WARNINGS/PRECAUTIONS:
General cautions for all AcrySof® and AcrySof® UV IOLs: Careful preoperative evaluation and sound clinical judgment should be used by the surgeon to decide the risk/benefit ratio before implanting any IOL in a patient with any of the conditions described in the Directions for Use that accompany each IOL. Caution should be used prior to lens encapsulation to avoid lens decentration or dislocation. Viscoelastic should be removed from the eye at the close of surgery.
Additional Cautions associated with AcrySof® IQ ReSTOR® IOLs: Some patients may experience visual disturbances and/or discomfort due to multifocality, especially under dim light conditions. A reduction in contrast sensitivity may occur in low light conditions. Visual symptoms may be significant enough that the patient will request explant of the multifocal IOL. Spectacle independence rates vary with all multifocal IOLs; as such, some patients may need glasses when reading small print or looking at small objects. Clinical studies indicate that posterior capsule opacification (PCO), when present, may develop earlier into clinically significant PCO with multifocal IOLs.
Additional Cautions associated with AcrySof® IQ Toric, AcrySof® UV Toric and ReSTOR® Toric IOLs: Optical theory suggests that, high astigmatic patients (i.e. > 2.5 D) may experience spatial distortions. Possible toric IOL related factors may include residual cylindrical error or axis misalignments. Toric IOLs should not be implanted if the posterior capsule is ruptured, if the zonules are damaged, or if a primary posterior capsulotomy is planned. Rotation can reduce astigmatic correction; if necessary lens repositioning should occur as early as possible prior to lens encapsulation.
Prior to surgery, physicians should provide prospective patients with a copy of the appropriate Patient Information Brochure available from Alcon informing them of possible risks and benefits associated with the AcrySof® IQ Toric, AcrySof® IQ ReSTOR® and AcrySof® IQ ReSTOR® Toric IOLs.
Do not resterilize. Do not store at temperatures over 45° C. Use only sterile irrigating solutions to rinse or soak IOLs.
ATTENTION: Refer to the Directions for Use labeling for the specific IOL for a complete list of indications, warnings and precautions.
