†New Classification of OVDs, 2005, modified and updated to 2015

STEVE ARSHINOFF, MD. FRCSC
ASCRS 2015 Understanding OVDs Course 2467 Handout
1. Theme & goals of Course:
The course is designed to assist attendees in understanding:
1.1. How far we have come in learning how to characterize ophthalmic viscosurgical devices, in a manner that relates
directly to our uses of them in surgery.
1.2. How the rheological characterization of OVDs leads directly to classification, which permits us to study the
similarities and differences among available OVDs.
1.3. How the classification of a given OVD can help us understand how to use it best in different situations.
1.4. How phaco is rheology, and how understanding OVD rheology helps us perform better phaco surgery.
1.5. How rheologic information helps us design newer better OVDs.
2. The roles of OVDs in surgery
2.1. To create and preserve surgical spaces – viscosity / elasticity.
- best achieved with most viscous-cohesive OVD
2.2. To partition spaces – including endothelial protection
- best achieved with lower viscosity dispersives.
2.3. To provide a low viscosity space to perform surgery.
- best achieved in a BSS space.
3. Historic and Current Classification of OVDs.
3.1. Differences between dispersion and pseudo-dispersion .
- viscoadaptives, at high shear are pseudispersive.
4. Zero-shear Viscosity and Cohesion, & how to measure them.
CLASSIFICATION OF OVDs
VISCOADAPTIVES
Healon5, iVisc Phaco, Microvisc Phaco
HIGHER VISCOSITY COHESIVES
Healon, HGV, iVisc,
ProVisc Amvisc
LOWER VISCOSITY DISPERSIVES
Viscoat, HEndocoat,
HPMCs,
• Ultra viscous-­‐cohesive • Pseudo-­‐dispersive (solid)
• Create space
• Induce & sustain pressure
• Prolonged retention
• Partition spaces.
Viscous-­‐
Dispersive
(DisCoVisc,
Amvisc Plus ?)
• Viscosity of Healon
• Dispersion of Viscoat
4.1. Pseudoplasticity curves, Cohesion - Dispersion Index (CDI)
†New
Classification of OVDs, 2005, modified and updated to 2015
" Cohesive - Dispersive !
!!
V0 (zero-shear viscosity) range
(mPa.s)
Cohesive OVDs
CDI ≥ 30 (% asp / mm Hg)
7- 18 x 106 (ten millions)
Dispersive OVDs
CDI < 30 (% asp / mm Hg)
I. V i s c o a d a p t i v e s
* Healon5*
iVisc**(MicroVisc***) Phaco, BD MultiVisc#
1 - 5 x 106 (millions)
II. Higher viscosity cohesives
A. Super viscous cohesives
*Healon GV*
iVisc** (MicroVisc***, HyVisc***) Plus
BD Visc#, AcriHylon Plus##
B. Viscous cohesives
*Healon*
iVisc** (MicroVisc***, HyVisc***)
Eyefill HC###
Ophthalin Plus##
*Provisc†
Opegan Hi††
*Biolon Prime†††
*Biolon†††
*Amvisc
Ophthalin##
Eyefill SC###
Viscosity !
105 - 106 (hundred thousands)
III. Lower viscosity cohesives
104 - 105
(ten thousands)
A. Medium viscosity cohesives
none
†Modified
from:
Arshinoff SA, Jafari M. A new
classification of ophthalmic
viscosurgical devices (OVDs). J
Cataract Refract Surg. 2005; 31:
2167-2171
103 - 104
SA
(thousands)
Legend:!! * Abbot Medical Optics,
Research
B. Very low viscosity cohesives
none
** iMed Pharma, *** Bohus Biotech, # Bectin Dickinson, ## Carl Zeiss Meditech,
††† Biotechnology Technology General,
Rayner,
Shisheido Co., †† Seikagaku Corporation - Santen,
II. Higher viscosity dispersives
A. Super viscous dispersives
none
B. Viscous dispersives
* DisCoVisc†
* Amvisc Plus
III. Lower viscosity dispersives
A. Medium viscosity dispersives
*Viscoat†
Biovisc*
Endogel##
Rayvisc
Opelead
*Vitrax*, Healon D*, Healon Endocoat*
*Cellugel†
B. Very low viscosity dispersives
Opegan††, Eyefill HD###
*OcuCoat
Icell**, Visilon, Ocuvis, Hymecel,
Adatocel, Celoftal, ...HPMCs
### Croma Pharma, † Alcon laboratories,
HPMC = hydroxypropylmethylcellulose,
2115 Finch Ave. W, Suite 316, Toronto, Ontario, Canada M 3 N 2 V 6 . Tel: (416) 745-­‐6969 Fax: (416) 745-­‐6724 Email: i [email protected] Bausch & Lomb
* Available in USA
STEVE ARSHINOFF, MD. FRCSC
ASCRS 2014 Understanding OVDs Course
Page 2
5. Surgical OVD Techniques leading to Tri-Soft Shell Technique
5.1. Soft Shell Technique (SST).
Viscoat (low viscosity dispersive) injected first onto the
surface of the lens, followed by a viscous cohesive, which
pushes the dispersive up into a smooth layer against the
endothelium, providing a protective layer, with a smooth
fracture boundary separating the two OVDs.
5.1.1. Routine Cases
5.1.2. Fuchs’ Dystrophy
5.1.3. Broken Zonule cases (with CTR)
5.1.4. Small holes in posterior capsule
5.1.5. Isolating Frayed Iris
5.2. Achieve clean posterior capsules with BSS irrigating jet.
ULTIMATE((SOFT((SHELL(TECHNIQUE((USST)*(
5.3. Healon5 & Ultimate Soft Shell Technique (USST)
- uses viscoadaptive and BSS (instead of dispersive).
- makes all cases much easier, and more stable.
Pre Capsulorhexis Step
5.3.1. Viscoadaptive rheology – how its different
5.3.2. Routine cases
5.3.3. Capsular Dye cases
5.3.4. USST for IOL injector cartridges
5.3.5. Adding BSS under all OVDs in all cases
5.4. SST-USST combinations ! Tri-Soft Shell Techniques.
- use layers of dispersive against the cornea, viscous
cohesive centrally to establish stability, and BSS
(or XYLO-PHE) on the lenticular surface (for a
low-viscosity surgical space). Optimizes pupil dilation
and makes cases easier.
5.4.1. General use
5.4.2. Fuchs Dystrophy – low endothelial cell counts
5.4.3. Flomax IFIS Soft Shell Bridge (SSB) technique
5.4.4. Worst case scenario TSST cases
Pre IOL Implantation Step
SA
*Arshinoff Steve A. Using BSS with viscoadaptives in the ultimate soft-shell technique. J Cataract Refract Surg. 2002 Sep;28(9):1509-14.
Research
Flomax IFIS Soft Shell Bridge (SSB)
2. Viscoadaptive
filled space
1. Viscoat
filled space
(injected second)
3. BSS filled
space
(injected third)
(injected first)
Incision
5.5. Special circumstances
5.5.1. Can 1 OVD do it all – DisCoVisc?
5.5.2. Natural lens present – phakic IOLs
5.5.3. Exposed vitreous face – Secondary IOLs, no capsule.
6. OVDs & IOP
6.1. Do some OVDs cause worse IOP spikes than others?
6.2. Do post op IOP spikes suggest undiagnosed glaucoma?
6.3. Most effective drugs to prevent and treat IOP spikes?
6.4. Organized IOP spike management plan.
6.5. Preventing IOP spikes: OVD removal techniques
Cohesion-­‐Dispersion Index vs Log V0 *Variation of Healon5
NaHa OVDs: CDI related to Log V 0
Cohesion Dispersion
Index
6.5.1. Rock & Roll Technique
6.5.2. Two Compartment Technique
6.5.3. USST removal of OVDs
7. The science of OVDs
7.1. Measuring cohesion-dispersion indices
7.2. Healon5 lies on the boundary of fluids and solids.
7.3. Designing new OVDs
Fluid
80
VISCOAT
Solid
DISCOVISC
60
HEALON
Enhanced
retention
during
phaco
40
PROVISC
HEALON GV
20
HEALON5
0
iVISC Phaco
0
2
4
6
Log Zero Shear Viscosity (PaS)
SA
Research
*Arshinoff SA, Jafari M, Koushan Keyvan. OVD Use Enhanced by Cohesion Data.
ASCRS San Francisco Mar 18-23, 2006: Winner: Best Poster Cataract Section.
STEVE ARSHINOFF, MD. FRCSC
ASCRS 2014 Understanding OVDs Course
Page 3
References:
1. Arshinoff Steve: Rock ‘n’ Roll Removal of Healon GV (video). ASCRS Film Festival, Seattle, Washington. June 1-5,
1996.
2. Arshinoff Steve A: Rock ‘n’ Roll Removal of Healon GV in Arshinoff Steve A. Ed. Proceedings of the 7th annual
National Ophth.
Speakers Program (Ottawa, Canada, June 1996). Medicopea 1997: 29-30.
3. Tetz MR, Holzer MP. Two-compartment technique to remove OVDs. J Cataract Refract Surg. 2000. 26:5;641-643.
4. Arshinoff Steve: The Dispersive/Cohesive viscoelastic soft shell technique for compromised corneas and anterior chamber
compartmentalization. Winner, Surgical Techniques category. American Society of Cataract and Refractive Surgery Film
Festival, Seattle, Washington. June 1-5, 1996.
5. Poyer John F., Chan Kwan Y., Arshinoff Steve A: A new method to measure the retention of viscoelastics on a rabbit
corneal endothelial cell line after irrigation and aspiration. J. Cat. Refract. Surg. 1998: 24,1, 84-90 (January).
6. Poyer JF, Chan KY, Arshinoff SA: A quantitative method to determine the cohesion of viscoelastic agents by dynamic
aspiration. J. Cat. Refract Surg. 1998; 24: 8; 1130-1135, August.
7. Arshinoff Steve A: Dispersive-cohesive viscoelastic soft shell technique. J. Cataract Refract Surg. Feb. 1999. 25: 2;167173.
8. Arshinoff Steve. Using viscoelastics to solve problems in cataract surgery. Video. American Society of Cataract and
Refractive Surgery, Annual meeting April 16-22, 1998 video film festival. Runner up award - Cataract complications
section.
9. Arshinoff Steve. New terminology: Ophthalmic viscosurgical devices. Guest editorial. J. Cat Refract Surg. May 2000. 26:
5; 627-628.
10. Arshinoff Steve A. Using BSS with viscoadaptives in the ultimate soft-shell technique. J Cataract Refract Surg. 2002
Sep;28(9):1509-14.
11. Arshinoff SA, Albiani DA, Taylor-Laporte J. Intraocular pressure after bilateral cataract
surgery using Healon, Healon5, and Healon GV. JCRS. 2002 Apr; 28(4):617-25.
12. Arshinoff SA, Wong E. Understanding, retaining, and removing dispersive and pseudodispersive OVDs. J Cataract Refract Surg 2003: 29:12; 2318-2323.
13. Arshinoff Steve A. Letter. Capsular dyes and the USST. JCRS 2005; 31: 259-260. (Feb).
14. Arshinoff Steve A, Jafari Masoud. A New Classification of Ophthalmic Viscosurgical
Devices (OVDs) -2005. J Cataract Refract Surg 2005; 31:2167-2171. (Nov).
15. Arshinoff SA. Modified SST–USST for tamsulosin-associated intraocular floppy-iris
syndrome. J Cataract Refract Surg 2006; 32:559–561 (April); erratum, 1076.
16. Arshinoff SA. Suffering & pain lead to creativity. Cat. & Refractive Surg. Today 2010: 1: 1-3.
17. Arshinoff SA, Norman R. Tri-soft shell technique. JCRS 2013; 39: 1196-1203.