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Viscoadaptive OVD provides endothelial cell protection in special cases
Healon5 must be removed by aspirating behind the IOL. The technique is worth knowing for special cases, a surgeon says.
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A viscoadaptive material can be a valuable tool in certain cases, but special techniques should be learned in order to use it most effectively, according to one surgeon familiar with the device.
![Douglas A. Katsev, MD [photo]](/images\OSN\200602b\katsev.jpg) Douglas A. Katsev |
Removing Healon5 (sodium hyaluronate 2.3%, Advanced Medical Optics) from behind an IOL may be a challenge at first, but the technique is valuable to learn for use in specific cases, said Douglas A. Katsev, MD.
Healon5 is an ophthalmic viscosurgical device (OVD) that has been called a viscoadaptive, meaning that it can act as both a dispersive and cohesive material.
“Healon5 allows me to do cases comfortably and safely that I would not be able to do with other viscoelastics because of both its protective quality and its ability to move tissue and maintain space,” Dr. Katsev said.
Because of its high protective quality, Dr. Katsev said he prefers to use Healon5 in special cases, such as cataract patients with Fuchs’ dystrophy. It takes some patience and experience to remove the material from behind the IOL, he said, but the extra step is worth taking because of the protection it affords.
“I think it’s a great safety tool to use in those special cases. Although I could easily use it on 100% of my cases, from an efficiency standpoint, I like to use it when I need it,” he said. “When you need that extra protection, Healon5 is going to save you, and it is a great tool to have in mind.”
Special cases
Dr. Katsev said he does not use Healon5 for 100% of his cataract surgeries, but uses it for 100% of his cataract patients with Fuchs’ dystrophy to protect their endothelial cells.
“I used to do it for every standard case when I was first learning to use it, and I could easily do that, but it does require a little extra care,” he said. “It’s like a stabilizer ring. When I need it, I really need it, but I don’t need it on every case.”
When Dr. Katsev sees the patient preoperatively, he decides whether he will use Healon5 for that case.
“I write it on the chart, and when it comes time for the surgery, the surgery center puts Healon5 on the surgical tray. When I see that, I know I have a special patient that I need to take extra care of during surgery. It not only protects the patient, but it alerts me in a busy practice that this is not just a standard phaco.”
Protecting the endothelium in these patients reduces the risk of their needing a corneal transplant later, Dr. Katsev said.
“If I see a patient with Fuchs’ dystrophy, I am concerned about any damage to those cells that would cause corneal edema and lead to the need for a corneal transplant. For 100% of those patients, I feel I need to use Healon5,” he said. “I’ve done pachymetry studies of corneal thickness for 4 weeks after surgery, and I find that … the corneal thickness increased the least with Healon5, meaning those cells were protected the most when I used Healon5.”
Deeper wound tunnels
Dr. Katsev said that when he uses Healon5 during cataract surgery, he situates his tunnel incision slightly more anterior than usual. He suggested tunneling more anteriorly in the wound with Healon5 to prevent iris prolapse.
“Healon5 is cohesive enough that if your wound is not very good, it will burp out of the eye and cause suction or negative pressure, and the iris can follow the Healon5 into the wound,” he said. “Once the iris finds its way into the wound it has great memory and keeps trying to come back.”
Dispersive and cohesive
Dr. Katsev said Healon5 can act as both a dispersive and cohesive viscoelastic.
During high-flow-rate phacoemulsification, turbulence in the anterior chamber breaks Healon5 apart, and it behaves like a dispersive OVD, which is important for safely removing the cataract, Dr. Katsev said.
“It breaks off and stays completely in the anterior chamber and creates a thick bed of viscoelastic that protects those endothelial cells when the instrument is vibrating to remove the cataract from below,” he said.
When movement in the anterior chamber is less turbulent, the Healon5 behaves cohesively, allowing it to be used to move tissue and maintain space, Dr. Katsev said.
“You can fill in the capsule behind the IOL and slowly pull it out, and it will move together and you will remove all the Healon5 from behind the IOL, so you don’t have to take out individual pieces as you do with a dispersive,” he said.
An important step
For new surgeons, Healon5 can be a challenge to remove after the IOL is in place, but if it is done correctly the entire bolus of viscoelastic can be removed, Dr. Katsev said.
“It is a little harder to get out of the eye, but it is cohesive. If done appropriately, it will completely remove all the Healon5, and pressures will be low,” he said. “If it is done inappropriately and you don’t take your time to remove it, the pressures will be high.”
To effectively remove Healon5, it is important to go behind the IOL and allow the tip of the irrigation and aspiration instrument to sit in the middle of the capsule behind the IOL, Dr. Katsev said.
“Push your foot pedal down to start irrigation and aspiration, and hold it there until the Healon5 starts coming,” he said. “You wait, and it will come, but you have to be patient. It doesn’t all come right away. It may take 60 seconds to remove all the Healon5.”
After the OVD is removed, the IOL should center itself and move freely in the capsule, Dr. Katsev said.
Behind the IOL
Some surgeons may be concerned with putting the I&A instrument behind the IOL, Dr. Katsev said, but he said the Healon5 displaces tissue and creates an area to insert the instrument without causing damage.
“With experience you’ll definitely understand how it works,” he said. “There’s a different quality to Healon5 than regular viscoelastic, and you will see a pattern change behind the IOL.”
If there is any doubt that Healon5 has not been completely removed, the surgeon should attempt to spin the IOL and see if it moves freely, he said.
Dr. Katsev recommends that inexperienced surgeons familiarize themselves with Healon5 on standard cases before attempting to use it for specialty cases, such as patients with Fuchs’ dystrophy.
“If you do the few steps to remove the Healon5 and prevent it from burping out of the eye by tunneling anterior you will find it a great tool in these difficult cases,” he said.
For Your Information:
- Douglas A. Katsev, MD, can be reached at the Sansum Santa Barbara Medical Foundation Clinic, 29 W. Anapamu St., Santa Barbara, CA 93101; 805-681-8930; fax: 805-568-1933; e-mail: katsev@aol.com. Dr. Katsev is a consultant to Advanced Medical Optics, but he has no financial interest in the products mentioned.
- Advanced Medical Optics, maker of Healon5, can be reached at 1700 E. St. Andrew Place, Santa Ana, CA 92799; 714-247-8200; fax: 866-872-5635; Web site: www.amo-inc.com
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.