Ophthalmic Viscosurgical Device Injection Research Articles

Visualization of Cataract Surgery Steps With 4D Microscope-Integrated Swept-Source Optical Coherence Tomography in Ex Vivo Porcine Eyes.

To investigate the visualization capabilities of high-speed swept-source optical coherence tomography (SS-OCT) in cataract surgery. Cataract surgery was simulated in wet labs with ex vivo porcine eyes. Each phase of the surgery was visualized with a novel surgical microscope-integrated SS-OCT with a variable imaging speed of over 1 million A-scans per second. It was designed to provide four-dimensional (4D) live-volumetric videos, live B-scans, and volume capture scans. Four-dimensional videos, B-scans, and volume capture scans of corneal incision, ophthalmic viscosurgical device injection, capsulorrhexis, phacoemulsification, intraocular lens (IOL) injection, and position of unfolded IOL in the capsular bag were recorded. The flexibility of the SS-OCT system allowed us to tailor the scanning parameters to meet the specific demands of dynamic surgical steps and static pauses. The entire length of the eye was recorded in a single scan, and unfolding of the IOL was visualized dynamically. The presented novel visualization method for fast ophthalmic surgical microscope-integrated intraoperative OCT imaging in cataract surgery allowed the visualization of all major steps of the procedure by achieving large imaging depths covering the entire eye and high acquisition speeds enabling live volumetric 4D-OCT imaging. This promising technology may become an integral part of routine and advanced robotic-assisted cataract surgery in the future. We demonstrate the visualization capabilities of a cutting edge swept-source OCT system integrated into an ophthalmic surgical microscope during cataract surgery.

Comparative study of the three-dimensional perception of videos recorded on a "Do it yourself" three-dimensional recording assembly versus the conventional recording system.

To develop an indigenous "Do it yourself" (DIY) three-dimensional (3D) ophthalmic surgery recording system and validate the perception of stereopsis using it. A cross-sectional survey of practicing ophthalmologists with post-postgraduation experience of at least 5 years for perception of stereopsis for three different surgeries was performed; cataract, retinal detachment, and intravitreal drug injection were recorded on DIY assembly, viewed on VRBOX and using laptop videos and pseudo 3 d videos as control. The laptop videos and 3D VR Box videos received higher ratings for stereopsis than the pseudo 3D videos. The parameters that received significantly higher ratings on the 3D VR Box viewing were instrument's position relative to the ocular surface in cataract surgery, anterior chamber depth during capsular staining, ophthalmic visco-surgical device injection, capsulorhexis, phaco tunnel depth, movement of nuclear fragments in the anterior chamber, and intra-ocular lens tilt in the capsular bag during cataract surgery ( P < 0.05). In scleral buckling surgery, the parameters that were significantly rated higher on VR Box were globe contour, separation of the scleral plane from muscle, and explant plane ( P < 0.05). Furthermore, the depth of the needle in the vitreous cavity while administering intravitreal drug injection was also rated significantly higher on VR Box ( P < 0.05). However, the ratings for the depth of corneal incision, depth of scleral incision, overall color, and overall quality were not different statistically when compared between laptop and VR Box viewing. DIY 3D recording assembly offers a superior means of appreciating depth at various stages of cataract surgery, scleral buckling, and intravitreal drug injection when compared to laptop viewing and can serve as an effective tool for skill transfer.

A case of mitomycin C toxicity after XEN gel stent implantation with the XEN air technique in a glaucoma patient

BackgroundTo discuss the first case of mitomycin C (MMC) toxicity after XEN® gel stent implantation in a glaucoma patient, conducted using the XEN “air” technique with an ophthalmic viscosurgical device (OVD).Case presentationA 44-year-old Asian male presented with increased intraocular pressure (IOP; 52 mmHg) accompanied by keratic precipitates and an edematous cornea. He was diagnosed with uveitic glaucoma in the left eye, and the IOP was controlled with a topical anti-glaucoma agent. However, glaucoma progression was revealed by Humphrey visual field (HVF) and optical coherence tomography (OCT) examinations. The patient underwent uneventful XEN gel stent implantation using the XEN air technique and an MMC (0.02%, 0.1 mL) injection, with subconjunctival air and OVD injection provided prior to XEN implantation in the left eye. The patient exhibited a decreased IOP (11 mmHg), elevated bleb, and extensive subconjunctival hemorrhage on postoperative day 1. On postoperative day 18, diffuse conjunctival injection and a large avascular bleb was noticed around the XEN gel stent. The patient complained of severe eye pain and discomfort, suggestive of MMC toxicity, and the IOP was 12 mmHg. The patient was treated with a topical steroid and antibiotics tapered over a 6-month period. Finally, the toxicity was successfully controlled, with the IOP stabilizing at around 15 mmHg.ConclusionsAlthough significantly greater lowering of the IOP can be expected with the use of subconjunctival OVD injection and MMC during XEN gel stent implantation, a cautious approach and a longer monitoring period are required.

A Modified Femtosecond Laser Technique for Anterior Capsule Contraction Syndrome.

Anterior capsule contraction syndrome (ACCS) is a rare, late complication of cataract surgery, associated with impairment of visual function. In this paper, we describe a new surgical technique to treat ACCS by femtosecond laser procedure. The femtosecond laser was used to perform an anterior capsulotomy with a customized size, in order to avoid IOL damage. After ophthalmic viscosurgical device injection in the anterior chamber, the anterior capsule flap was separated from the IOL surface by gentle hydrodissection. This manoeuvre enabled an easy and safe removal of the fibrotic material by vitreal microscissors. Our technique allowed a complete removal of the fibrotic material and opening of the capsule, with immediate complete visual acuity recovery without IOL damage. In conclusion, femtosecond laser appears to be safe and effective for treatment of ACCS with long-lasting efficacy.

Clinical outcomes of management of posterior capsule rupture with air bubble techniques.

To introduce a new surgical technique, air-bubble technique for the management of posterior capsule rupture (PCR) and to evaluate the safety and efficacy of the technique. A retrospective case series analysis of 24 eyes of 24 patients, in which the air bubble technique was used for the management of PCR, was performed. Once PCR occurred, a dispersive ophthalmic viscosurgical device (OVD) was injected into the tear. And small volumes (0.2-0.3 mL) of air bubbles were injected beneath the OVD. The air bubble served as a physical barrier and supported the posterior capsule. After surgery, none of the patients had serious complications during the follow-up period of 1y. Extension of the PCR size occurred in only 2 cases, and additional OVD injection was required only in 3 cases. Air bubbles imparted great stability to the nuclear pieces and the posterior capsule. The air-bubble technique may be considered a safe and effective procedure for managing a PCR. It may be of value to the inexperienced cataract surgeon.

Evaluation of preloaded intraocular lens injection systems: Ex vivo study

To compare preloaded intraocular lens (IOL) injection systems. Sussex Eye Hospital, Brighton, United Kingdom. Experimental study. In 30 porcine eyes, 5 preloaded +22.0 diopters IOLs were implanted from each of the following preloaded IOL systems: Ultrasert (U), iTec (iT), Eyecee (E), iSert (iS), Rayone (R), and CT Lucia (CT). External and internal wound size was measured. Nozzle damage was assessed using digital photography. The ease of opening the pack, ophthalmic viscosurgical device (OVD) injection, advancing into the nozzle, nozzle insertion, and IOL delivery was scored on a 4-point Likert scale, and the time was recorded. The iT, E, and iS injectors with acute angled bevels andshorter nozzle tips showed more damage after implantation. Thefastest with regard to opening the pack and nozzle insertion was U, OVD injection and advancing into the nozzle was E, and IOL delivery was R. The maximum postimplantation wound stretch was 20% with the CT (mean 2.64mm±0.1 [SD]), and the least was 11.8% with the iT (mean 2.46±0.1mm). Both the U and R scored 4 (very easy) for all parameters measured; the E, iS, iT, and CT scored 4 or less in some parameters with decreasing scores, respectively. The models, design, and injection systems varied with each brand; however, the longer and more parallel the nozzle and less acute the angle of the bevel tip, the lesser the stress with less nozzle damage after surgery. All preloaded systems varied in the ease-of-use and time for surgical steps, and all lead to postoperative wound stretch.

The Use of Ophthalmic Viscosurgical Devices During Donor's Corneal Harvesting

Purpose of the study: To evaluate the protective effect of Biolon© (sodium-hyaluronate 1%) use on corneal endothelium, during donor's corneal harvesting.Materials and methods: A prospective, randomized, double blind, comparative study was performed on 120 corneas donated from 60 donors. One cornea from each donor (n = 60) was harvested using intracameral injection of ophthalmic viscosurgical device (OVD), and the fellow cornea with no use of OVD (n = 60, control group). Endothelial cell density (ECD) values were obtained at the center of each corneal graft with a specular microscope one day after harvesting.Results: ECD in the OVD group were 2839 ± 412.5 cells/mm2 and in the control group 2748 ± 429.7 cells/mm2. (p = 0.03). Distribution curve of the difference in ECD between the OVD and no OVD eyes showed that 47% of the donors had > 100 cells/mm2 difference, and 32% of donors had >200 cells/mm2 difference in favor of the OVD group.Conclusions: Intracameral OVD injection during corneal graft harvesting may protect the endothelium from the mechanical damage induced during the procedure. Further investigation is needed before routine the use of intracameral OVD should be considered in this setting.

Enlarging the Big-Bubble During Deep Anterior Lamellar Keratoplasty

During big-bubble deep anterior lamellar keratoplasty, a bubble that is not large enough can be formed. Further air injection can result in the rupture of the posterior lamella, necessitating conversion to penetrating keratoplasty. We describe some techniques to safely enlarge the big-bubble in such a circumstance. In cases in which a white-margin bubble forms that has extended to the trephination margin, the bubble is collapsed and the margins are extended by blunt dissection. For cases of an undersized clear-margin bubble, the bubble is enlarged by gentle injection of a cohesive ophthalmic viscosurgical device into the bubble cavity. Using these techniques, big-bubbles were safely extended beyond the trephination margin for both white- and clear-margin bubbles. An undersized big-bubble can safely be extended using blunt dissection for white-margin bubbles and ophthalmic viscosurgical device injection for clear-margin bubbles.

Bimanual capsulorrhexis using Sinskey hook

An adequately sized, intact capsulorhexis is a key to the outcome of any phacoemulsification procedure. Cystitome is widely used to create a continuous curvilinear capsulorhexis. A 'frozen' capsule (crumpled capsule) mixed with viscoelastic and cortex, however can result in loss of control while using a cystitome. The Sinskey's hook introduced through the side-port, can stabilize the globe as well as work in coordination with the cystitome to spread out the jumbled up anterior capsule allowing visualization of the tear edge in the Bimanual technique. The capsulorhexis is thereby completed comfortably obviating the need of capsulorhexis forceps or repeated injection of ophthalmic viscosurgical device.

Anterior capsule staining using micronized triamcinolone in the absence of red reflex

We describe a technique to stain the anterior lens capsule with micronized triamcinolone to perform a continuous curvilinear capsulorhexis (CCC) during phacoemulsification in the absence of a red reflex due to vitreous hemorrhage. After a self-sealing clear corneal tunnel incision is performed using a 2.75 mm blade, a dispersive ophthalmic viscosurgical device (OVD) is injected to protect the iridocorneal angle. An air bubble as large as possible is injected into the center of the anterior chamber, and a small amount of micronized triamcinolone is then injected as needed to stain the anterior lens capsule. The OVD injection permits the removal of excessive triamcinolone and protects the corneal endothelium from damage during phacoemulsification. A capsulorhexis forceps is used to perform the CCC. No author has a financial or proprietary interest in any material or method mentioned.

Posterior-assisted levitation: Outcomes in the retrieval of nuclear fragments and subluxated intraocular lenses

To report the outcomes of posterior-assisted levitation (PAL) to retrieve nuclear fragments and subluxated intraocular lenses (IOLs). Singapore National Eye Centre, Singapore, Singapore. In a retrospective series, the case notes of consecutive surgeries performed by a single surgeon between 1999 and 2006 were reviewed. Posterior-assisted levitation was performed for intraoperative posterior capsule rupture with nucleus-IOL dislocation or for late subluxation of posterior chamber intraocular lenses (PC IOLs). This was accomplished by the pars plana insertion of a needle followed by levitation of the subluxated object. Ophthalmic viscosurgical device injection was not used as an adjunct for levitation. Fourteen patients with PAL were followed for a mean of 18.71 months (range 1 to 79 months). There were 3 cases of dropped nucleus/nuclear fragments, 1 case of intraoperative subluxated PC IOL, and 10 cases of late subluxated PC IOLs. Complications included 1 case of retinal detachment occurring 20 months after PAL and 1 case of cystoid macular edema in a patient with previous anterior uveitis. Best corrected visual acuity was 20/40 or better in all except 3 patients (1 retinal detachment, 1 corneal edema/scarring, 1 unspecified). Posterior-assisted levitation provided an effective, relatively noninvasive means of levitating nuclear fragments and PC IOLs with few complications.

Fate of anterior capsule tears during cataract surgery

To determine the incidence of anterior capsule tears, at what stage of surgery they occurred, and their intraoperative behavior. Ambulatory surgery center, Cincinnati Eye Institute, Cincinnati, Ohio, USA. This 5-year retrospective study was of patients having phacoemulsification with posterior chamber intraocular lens (IOL) implantation complicated by unplanned peripheral extension of the capsulorhexis tear or a radial anterior capsule tear. The operative notes and a videotape of the surgery were reviewed. The stage at which the tear was initially observed and when it extended were identified, as was whether the tear extended to the posterior capsule. Anterior vitrectomy and the design and location of the IOL implanted were also analyzed. A discontinuous anterior capsulorhexis or a break in the anterior capsule rim was observed in 21 eyes of 2646 cases, for an overall incidence of 0.79%. Anterior capsule tears were identified during ophthalmic viscosurgical device injection in 1 eye, capsulorhexis in 13 eyes, hydrodissection in 2 eyes, phacoemulsification in 3 eyes, irrigation/aspiration (I/A) in 1 eye, and implantation of a prosthetic iris device in 1 eye. Seven of the 13 tears identified during the capsulorhexis were managed by redirecting the second edge of the "safety" capsulorhexis to incorporate the tear. In 14 eyes, the tear in the anterior capsule extended into the zonules; 4 of these tears were limited. Ten tears extended around the equator and through the posterior capsule, occurring during the hydrodissection in 1 eye, phacoemulsification in 2 eyes, I/A in 1 eye, and IOL implantation in 6 eyes. An anterior vitrectomy was required in 4 eyes that had posterior capsule involvement. Endocapsular fixation of a 1-piece acrylic IOL was achieved in 18 eyes. Three eyes required implantation of a 3-piece acrylic IOL in the ciliary sulcus. Extension of an anterior capsule tear can complicate cataract surgery at any stage. Extension of the tear through the posterior capsule occurred in almost half the eyes with an anterior capsule tear, often requiring an anterior vitrectomy. Managing an anterior capsule tear can be challenging yet compatible with implantation of a posterior chamber IOL.

Intraocular pressure during phacoemulsification

To assess changes in intraocular pressure (IOP) during standard coaxial or bimanual microincision phacoemulsification. Oregon Eye Center, Eugene, Oregon, USA. Bimanual microincision phacoemulsification (microphaco) was performed in 3 cadaver eyes, and standard coaxial phacoemulsification was performed in 1 cadaver eye. A pressure transducer placed in the vitreous cavity recorded IOP at 100 readings per second. The phacoemulsification procedure was broken down into 8 stages, and mean IOP was calculated across each stage. Intraocular pressure was measured during bimanual microphaco through 2 different incision sizes and with and without the Cruise Control (Staar Surgical) connected to the aspiration line. Intraocular pressure exceeded 60 mm Hg (retinal perfusion pressure) during both standard coaxial and bimanual microphaco procedures. The highest IOP occurred during hydrodissection, ophthalmic viscosurgical device injection, and intraocular lens insertion. For the 8 stages of the phacoemulsification procedure delineated in this study, IOP was lower for at least 1 of the bimanual microphaco eyes compared with the standard coaxial phaco eye in 4 of the stages (hydro steps, nuclear disassembly, irritation/aspiration, anterior chamber reformation). There was no consistent difference in IOP between the bimanual microphaco eyes and the eye that had standard coaxial phacoemulsification. Bimanual microincision phacoemulsification appears to be as safe as standard small incision phacoemulsification with regard to IOP.