Transcript Healon5 Visco-sandwich Technique for Phacoemulsification

Healon5 Visco-sandwich Technique
for Phacoemulsification
in Morgagnian Cataract Surgery
Masaki Sato, MD
Tetsuro Oshika, MD
Department of Ophthalmology
University of Tsukuba
Japan
The authors have no commercial or proprietary interest in any of the
companies, products, or methods described in this presentation.
Introduction

A morgagnian cataract is a hypermature lens in which the total
liquefaction of the cortex and the dense nucleus sinks inferiorly.
Aside from the total reduction of vision, serious sequelae such as
phacolysis may result.

Phacoemulsification for morgagnian cataract, which many
ophthalmic surgeons would hesitate to perform, demands highdegree skill and considerable experience from the operator. The
fluctuating anterior capsule complicates creating a CCC.
Additionally, the complete outflow of the liquefied cortex at the
very beginning of creating a CCC can result in high rates of the
posterior capsule rupture during PEA.

We expected that a technique which wrapped the morgagnian
hard nucleus in the “visco-shell” made of Healon®5 (AMO, Inc.)
brought high ability to maintain both intracameral and
intracapsular stability during PEA (Figure 1).
A
B
C
D
Figure 1. The outline of Healon5 visco-shell (visco-sandwich) technique.
A) Healon5 injection into the anterior chamber. B) Additional Healon5 injection
between the nucleus and the posterior capsule. C) In the visco-shell made of
Healon5, PEA under lowered fluidics is meticulously performed. D) Theoretically,
the visco-shell is expected to retain its original form at the copletion of PEA.
Purpose

To investigate the efficacy of Healon5
visco-shell (visco-sandwich) technique
for phacoemulsification in morgagnian
cataract surgery.
Subjects

3 eyes of three patients with typical
morgagnian cataract had PEA and IOL
implantation from December 2006
through June 2007.
Surgical Technique
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The USST using Healon5 and typan blue 0.1%

CCC
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No hydrodissection
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Healon5 visco-shell (visco-sandwich) technique
Healon5 injection between the lens nucleus and the posterior capsule
to lift the entire nucleus and expand the capsular bag.
The nucleus is slightly subluxated out of the bag.

Phaco-chop technique in the middle of the visco-shell

Parameters during phacoemulsification
vacuum 180 mm Hg, AFR 20 cc/min, phaco power 70%,
ultrasound pulse rate 10 pulses/sec, and bottle height 80 cm.

No suction of cortex

Healon5 intracapsular re-injection

IOL intracapsular fixation
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The 2-compartment technique ( 500 mm Hg vacuum, 28 cc/min AFR)
a
b
c
d
e
f
h
i

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Figure 2.
Preoperative (a),
intraoperative (b-h),
and postoperative
(i) anterior segment
photographs of a
typical morgagnian
cataract patient.
g
b) At supine position, the lens nucleus sinks into the liquefied cortex. c) Outflow of the liquefied
cortex at the very beginning of a capsulorhexis (Arrows). d) Note that the intracapsular color
changes from white to brown in an instant. Asterisks Spilled cortex. e) Healon5 visco-shell
(visco-sandwich) technique. f) The slightly subluxated nucleus. g) PEA in the middle of the
visco-shell. The intracameral stability is extremely good. h) An IOL intracapsular fixation as usual.
i) No any postoperative complications POD 1.
Results
(In all eyes)
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Complete CCC, safe PEA, and IOL intracapsular fixation
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No any intraoperative complications
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Neither corneal edema nor Descemet´s fold on POD 1
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No postoperative IOP-lowering medication
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The endothelial cell loss rate POM 3 of under 10 %.
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No any postoperative complications
Discussion 1
( Visco-shell or Sandwich)
Q : Difference in stage of Healon5 jnjection

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Healon5 sandwich technique in vitrectomized eyes (Sudan et al.)
Injection under the second piece after half the nucleus is emulsified.
Healon5 visco-shell (visco-sandwich) technique in morgagnian cataract
eyes (Current study)
Injection under the whole nucleus prior to PEA.
Wrapping the whole nucleus in the “visco-shell” made of Healon5.
A : Nuclear size : Morgagnian cataract << Post-vitrectomized cataract
In case of a usual vitrectomized eye, it is not appropriate that Healon5
would be injected under the whole nucleus prior to PEA, because acute
IOP elevation might cause complications such as posterior capsule
dehiscence followed by nucleus drop into the vitreous cavity. In case of
an eye with a large CCC and complete hydrodelineation, however,
Healon5 might be injected at the early stage of PEA even if a
vitrectomized eye.
Discussion 2
( How to use Healon5 )
j
k
l
m
Typical or Atypical
Figure 3.
Atypical morgagnian cataract with
spontaneous posterior capsular
rupture (only a few cases reported).
j) A dislocated embryonic nucleus
oscillates simultaneously with eye
movement. k) Posterior capsule
adhered severely to anterior capsule.
l) Nucleus floating in the Berger's
space. m) Nucleus removal with socalled the visco-extraction technique.
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The visco-extraction technique is good enough for such a case !
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But, in case of typical morgagnian cataract as shown in Figure 2, what do you do ?
Using visco-shell (visco-sandwich) technique with a viscoadaptive OVD such as
Healon5, it is considered that phacoemulsification with the appropriate setting of
parameters can be performed safely irrespective of the surgeon's experience.
Discussion 3

( Another OVD)
DisCoVisc® (hyaluronic acid 1.65%-chondroitin sulfate 4%,
Alcon Laboratories, Inc.) : a viscous dispersive OVD
Retention : DisCoVisc >> Healon5
Removal : DisCoVisc >> Healon5

Closest to the ideal OVD, in that it remains in the eye when
necessary and is easy to remove at the end of surgery.
DisCoVisc may be able to be used instead of Healon5
in performing visco-shell (visco-sandwich) technique.
Conclusions

Healon5 visco-shell (visco-sandwich) technique has high
ability to maintain both intracameral and intracapsular
stability during phacoemulsification under lowered fluidics
in morgagnian cataract surgery.
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This technique may be also applied to cases in which the
rock-hard nuclear fragments would remain with no cortex
in usual cataract surgery.
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Our results encourage further investigations of the effect
of this technique on maintenance of intraocular stability
during phacoemulsification in various cases.