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Hydroview IOL performs well as follow-up nears 3 years
The Latin American experience has been good, and slightly different from the European experience with the lens.
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In the past 2.5 years, our group of four surgeons has implanted over 2,500 Hydroview lenses (Bausch & Lomb Surgical, Claremont, Calif.). Three of my fellow surgeons and I shared our findings about the Hydroview IOL at a Latin American users’ panel during the annual American Society of Cataract and Refractive Surgery (ASCRS) meeting in Seattle.
My experience with the Hydroview lens has been very promising and as a result, Hydroview has become the IOL of choice for me and my fellow surgeons who participated in the panel discussion. With its slow controlled unfolding, ease of insertion, excellent visual acuity, biocompatibility, superlative centration and minimally invasive lens technology, Hydroview has met and exceeded our expectations.
--- The lens is folded using its special packaging and is ready to be grasped by the insertion forceps.
Hydroview is an advanced hydrophilic acrylic lens featuring a unique one-piece foldable design. It combines the material and design advantages of an 18% water-content hydrogel optic and polymerically cross-linked PMMA haptics. It allows surgeons to use advanced microincision techniques without sacrificing the excellent stability and centration inherent in a one-piece design.
Dr. Oscar Castillo, clinical director of Clinica de Ojos in San Cristobal, Venezuela; Dr. Juan Shulz, clinical director of Unidad Oftalmologica in Maracay, Venezuela; Dr. Humberto Belloso, professor ad honorem at Zulia University and University Hospital in Maracaibo, Venezuela; and I presented a preliminary report of our experiences with implantation of the Hydroview lens 6 months after we began the study. Since then, we have been so satisfied with the results that we kept using the lens and, as time progressed, increased the frequency of implantation. Based on almost 3 years of experience, we gathered again to share our findings with the ophthalmic community at ASCRS.
New delivery system
---The lens is inserted. The incision has been enlarged to 3.6 mm. Note that the lens has been turned to the left and the haptics are oriented toward this side.
We use the H60M model of the lens. In our surgical technique, we routinely use topical intracameral anesthesia, a 3.6-mm clear corneal incision, a 6-mm continuous capsulorrhexis, and the supracapsular quick-chop phacoemulsification procedure.
Initially, Hydroview was available in a cartridge and it had to be folded with folding forceps before it could be inserted into the eye. I found that it is relatively easy to use this traditional method with Hydroview because the lens surface does not adhere to itself or to surgical instruments during folding and insertion. Since Hydroview became available in the SureFold delivery system that holds and folds the lens on the appropriate 12-o’clock to 6-o’clock axis as the cartridge is opened and squeezed, lens handling is even easier. The SureFold eliminates the need to fold the lens with forceps, thus saving surgeon time and effort.
--- The inferior haptic and part of the optic are in the anterior chamber. At this moment it is necessary to depress the lens to introduce the inferior haptic under the anterior capsule.
Next, using the insertion forceps, I dial the lens one-quarter of a circle to put the superior haptic in the bag. Following that, I remove the viscoelastic in order to avoid ocular hypertension. Because of the design of the C-loop haptics, once I put both haptics in the bag, the lens centrates perfectly. As Dr. Shulz reports, Hydroview’s PMMA haptics are very strong and provide the best rate of centration so that even in patients with capsular fibrosis, there are no problems with centration.
One of the best things about this lens is the very slow unfolding process, which makes the procedure really atraumatic for the eye. Implantation of the Hydroview lens results in a quiet eye immediately following surgery. The rate of inflammation is very low due to the lens’ excellent biocompatibility, and consequently there is no need for special post-surgical treatment. Dr. Shulz reports that his patients never had any postop inflammation problems with these lenses. He applies topical steroids, reducing the dosage on the sixth day postop, and discontinues the use of topical steroids altogether 2 weeks after surgery.
Evaluation of results
--- The optic is in the anterior chamber. It has been turned to the right and is now oriented vertically. Note that the superior haptic outside of the eye is still oriented to the left.
The lens’ performance was evaluated in relation to several factors: insertion characteristics, tolerance of the material, operative reaction, optical centration, biocompatibility and vision outcomes. Based on all these criteria, Hydroview performed exceptionally well.
The insertion is easily accomplished through a 3.6-mm corneal incision. Dr. Belloso has devised new insertion forceps, which make it possible to introduce the lens through a 3.2-mm incision. In-the-bag implantation of the haptics is very simple.
Tolerance to the lens material has been excellent, as well. For us, there has not been a single case of adverse reaction due to the lens material. Operative reaction has been minor. Special treatment was not needed in any case. Optical centration has been good due to the in-the-bag placement of the PMMA C-loop haptics.
Last but not least, visual acuity results are very promising. Seventy-eight percent of our patients had a final refraction within 0.5 D of the preoperative calculation. The use of a self-sealing microincision has enabled us to keep induced astigmatism to a minimum (an average induced astigmatism of 0.75 D). Overall, 97% of patients obtained best corrected visual acuity (BCVA) of 20/40 or better.
Hydroview is a highly biocompatible lens. That is why its implantation results in a quiet eye immediately following surgery and a low rate of inflammation. The unique benefits provided by biocompatibility have made Hydroview our lens of choice even in difficult to implant eyes.
Complications
---The folding forceps are opened and the lens unfolds slowly.
The rate of complications in our 2.5 years of follow-up has been very low. We had two cases of sunset syndrome, which of course are not related in any way to this lens. We had five cases of epithelial proliferation on the anterior surface of the lens, which did not require treatment. Importantly, anterior cell migration is not progressive and does not affect visual acuity. Epithelial cell migration levels off soon after surgery and does not require any treatment.
In our experience, the incidence of posterior capsule opacification (PCO) is low. PCO rates reported by surgeons who participated in the study ranged from 6% to 11.8%. The range of PCO rates can be attributed to differences in surgical technique and the way PCO is defined. Dr. Shulz, who recorded an 11.8% of PCO, defines PCO as loss of one or more lines of vision and glare and patient discomfort — findings that can be attributed to other factors, as well.
---Using Lester forceps, the lens is rotated toward the right. The superior haptic passes under the anterior capsule to rest in the bag.
Our cumulative observations and experience with Hydroview IOL implantation indicate that the PCO rate is not a result of the lens material as much as it is a result of surgical technique and individual patient characteristics. PCO also is related to the way the surgeon manages to place the lens against the posterior capsule to avoid cell ingrowth behind the lens.
We have found that making a larger capsulorrhexis than the average can decrease the rate of PCO. A capsulorrhexis of 6.5 mm minimizes the amount of epithelial cells, which, as you know, are located on the anterior capsule. In addition, we do a thorough cleaning of the cortical material of the posterior capsule to reduce PCO. We always use a sharp spatula in order to perfectly clean the posterior capsule. In my opinion, these two techniques explain the low incidence of PCO that we have seen in the study.
Light vs. dark irides
--- The lens is in perfect position, both haptics are in the capsular bag, and the optic is perfectly centered.
Of particular interest is the difference in outcome between the European and Latin American experiences. In Latin America, the rate of PCO is lower than in Europe, and it may have to do with the difference in the color of patients’ irides. We have found that dark irides require different operative procedures than light irides. Dark irides dilate more slowly than light irides and need more medication preoperatively. Despite the fact that dark irides maintain dilation better during surgery, there is no problem constricting the pupil at the end of the procedure. While it is generally believed that the operative reaction is greater in patients with dark irides than in those with light irides, neither my colleagues nor I have noticed this phenomenon when using the Hydroview lens.
Conclusions
Hydroview provides surgeons with advantages related to its unique design and highly biocompatible material. We found that this lens is easy to implant and provides excellent visual acuity, biocompatibility and excellent centration. Its good biocompatibility results in quiet eyes immediately following surgery, which eliminates the need for complex postop treatment.
Patients are able to see well soon after the surgery, with most reaching their BCVA within 24 hours after the procedure. The lens is well tolerated and maintains a natural ecosystem in the eye. In addition, the use of a microincision keeps the rate of surgically induced astigmatism to a minimum, allowing for excellent visual acuity results.
 |  |
| Two cases, 48 hours postoperatively. A clear cornea, almost no reaction, a round pupil and a very small corneal incision can be seen. | |
Last but not least, the Hydroview lens is so biofriendly that we recommend its use in children or in difficult and compromised eyes, including glaucoma patients, pseudoexfoliation cases, diabetic and vitrectomized eyes.
In one case that Dr. Shulz quoted from his practice, the Hydroview lens was implanted in the eye of a 21-year-old lupus erythematosus patient who had developed cataracts as a result of prolonged use of prednisone. In the year following implantation of the lens, this young woman has not had to take any medication for her eye. She has excellent vision, and at her request will have her second eye implanted with the Hydroview lens.
My colleagues and I have found the Hydroview lens to be excellent. More important, as the case of Dr. Shulz demonstrates, it enables us to utilize innovative technology to improve health and quality of life.
 Final refraction of our patients. In our series, 78% were within 0.5 D of the preop prediction. |  Final visual acuity of 20/40 or better was obtained in 97% of our patients. |
For Your Information:
- For more information on the Hydroview IOL, contact Bausch & Lomb Surgical, 555 W. Arrow Highway, Claremont, CA 91711; (800) 423-1871; fax: (909) 399-1525.