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OPHTHALMOLOGYCORNEAL RESULTS OF 5 DIFFERENT OVD´S IN PHACO
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Prospective Nonrandomized Prospective Nonrandomized Comparison of Different OVD´s in Comparison of Different OVD´s in Non-eventful PhacoemulsificationNon-eventful Phacoemulsification
ASCRS, 2008ASCRS, 2008Fernando Aguilera MDFernando Aguilera MD
NO FINANCIAL INTERESTNO FINANCIAL INTEREST
Introduction
OVD´s protection and space formation have allowed phaco to be the prefered method for cataract extraction in normal and complex cases
OVD´s clasification is based in numerical values of: zero shear viscosity and cohesionzero shear viscosity and cohesion
(Arshinoff;JCRS2005;31:2167-2171)
Ovd’s clasificationOvd’s clasification
Low Viscosity Low Viscosity DispersiveDispersive
ViscoadaptiveViscoadaptivess
andandSuperviscous Superviscous
CohesivesCohesives
ViscousViscousCohesiveCohesive
DisDisCoCoVisViscc™™
Viscoat®
Cellugel®
Ocucoat®
Healon®-GVHealon®-5
Healon®
Provisc®
Amvisc®
ViscoViscoDispersivDispersiv
ee
usa market ovd´s
objectiveobjective
Compare clinical results and machine Compare clinical results and machine parameters between different OVD´s in phacoparameters between different OVD´s in phaco
Viscodispersive:………… DiscoviscViscodispersive:………… Discovisc Viscoadaptive:…...……… Healon 5Viscoadaptive:…...……… Healon 5 Cohesive:…………………Biovisc , Amvisc PlusCohesive:…………………Biovisc , Amvisc Plus Combination (Di-Co)…… DuoviscCombination (Di-Co)…… Duovisc
Material and methodsprospective, comparative, nonrandomized
Data 200 patients non complicated M.C.T. phaco Same surgeon (FAZ) Infiniti OZiL, Intrepid FMS, 30° miniflared Kelman tip, Blended torsional-conventional burst phaco Pre-postop: complete ophthalmic exam ECC,PM,IOPEVALUATION (SUBJECTIVE)Transop: questionarie for each case of ovd transoperative behavior EVALUATION (OBJECTIVE):Measurement of CDE (cumulative delivered energy)
Measurement of BSS (electric weight with double pole extension)
1.-Phaco 2.-Cortex I/A 3.- Asp post-IOL implanation1.-Phaco 2.-Cortex I/A 3.- Asp post-IOL implanation
Postop. Evaluations : 1,7,30.60 days, including: ECC,PM,IOP,Postop. Evaluations : 1,7,30.60 days, including: ECC,PM,IOP,
Transoperative OVD behavior evaluation:1- Ease of injection2- Visibility 3- Pupil manipulation4- AC maintainance (ccc, Phaco) 5- IOL implantation 6- I/A post IOL
Mean Surgical Difficulty by OVD
0
1
2
3
Cataract Extraction IOL Insertion Overall
Dif
ficu
lty
Lev
el
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Results : subjective
Mean Ease of Injection and Visualization Post Injection1=Poor 2=Fair 3=Good 4=Excellent
0
1
2
3
4
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Lev
el o
f E
ase
Injection Visualization
Anterior Chamber Maintenance During Surgical Phases
0
1
2
3
4
5
Anterior Capsulotomy Phacoemulsification IOL Insertion
Mai
nte
nan
ce S
cale
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Mean Ocular Inflammation 1 Day Postoperatively
0
1
2
3
Edema Cell Flare
Infl
amm
atio
n L
evel
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Results objective
Percent of ECC Loss Pre- to 2 Months Post-Operatively
0
5
10
15
20
25
30
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Per
cen
t L
oss
Mean Endothelial Cell Count Pre- and Post-Operatively
0
500
1000
1500
2000
PreOp 1 Month Post 2 Months Post
cells
/mm
2
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Mean Pachymetry Pre- and Post-operatively
500
520
540
560
PreOp 1 Month Post 2 Months Post
um
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
2 Months Postop: % ECC Loss by CDE Level (All OVDs)
0
10
20
30
40
50
<5.0 >5 to <10 >10 to <15 >15 to <20 >20
CDE Range
% E
CC
Lo
ss
p = 0.0290
Note: A statistically significant difference (p = 0.0290 ) was found for % ECC loss by CDE level.
2 Month Postop: % ECC Loss by CDE Level
-10
0
10
20
30
40
50
60
<5.0 >5 to <10 >10 to <15 >15 to <20 >20
CDE Range
EC
C L
os
s
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
2 Month Postoperative: ECC Loss by BSS Volume
-10
0
10
20
30
40
50
60
70
?100 101-200 201-300
BSS Volume (mL)
cells
/mm
2
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
ECC Loss by CDE and BSS Levels
0
10
20
30
40
50
<5.0 >5 to <10 >10 to <15 >15 to <20 >20
CDE
cell
s/m
m2
?100 101-200 201-300
2 Months Postoperatively: Percent ECC Loss by Preoperative ECC
-10
0
10
20
30
40
ECC <1500 Preop ECC >1500 Preop
Per
cen
t L
oss
All OVDs DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
BioVisc Healon5 AmviscPlus
DisCoVisc* p < 0.05 p < 0.05 p < 0.05
DuoVisc* p < 0.05 p < 0.05 p < 0.05
AmviscPlus* p < 0.05
Note: * indicates OVD with statistically significantly less ECC loss per Tukey’s studentized range test .
% ECC Loss Preop to 2 Months Postop: Statistically Significant Pairs
Discusion
Higher energy of US was related to more ecc loss (CDE > 10)
Higher levels of BSS were related to more ecc loss ( > 100 ml)
Overall the Viscodispersive OVD (Discovisc) cataract cases had better clinical and subjective outcomes
Conclusion
Viscodispersive (Discovisc) and Dispersive-Cohesive combination (Duovisc) OVD´s produced less ECC loss and Corneal edema in Microcoaxial Torsional Phacoemulsification than Viscoadaptive and viscous cohesive OVD´s (statistically significant)(statistically significant)
Cohesive OVD´s were related to more ECC loss in harder cataracts and should not be used in grades 4 and above (worst case 49% loss)
Viscodispersive OVD´s (Discovisc) are indicated in any grade of cataract hardness
Thank you
Fernando Aguilera MD
Mean Number of OVD Vials Utilized per Case
0
0.5
1
1.5
2
2.5
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Via
l N
um
be
r
Mean Infiniti CDE Reading by OVD
0
2
4
6
8
10
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
CD
E
Mean Grade of Cataract by OVD1=Soft 2=Medium 3=Hard 4= Brittle
0
1
2
3
4
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Gra
de
Mean Estimated Percent of OVD Retention
0
3
6
9
12
15
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Per
cen
t
Mean Capsural Bag Maintenance During Surgery1=Poor 2=Fair 3=Good 4=Excellent
0
1
2
3
4
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Mai
nte
nan
ce S
cale
Mean Difficulty of OVD Aspiration1=Very Easy 2=Easy 3=Neither Easy or Difficult 4=Difficult 5=Very Difficult
0
1
2
3
4
5
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Dif
ficu
lty
Lev
el
Mean Effectiveness of Pupil Expansion1=Not Effective 2=Moderately Effective 3=Very Effective
0
1
2
3
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
Eff
ec
tiv
en
es
s L
ev
el
Mean Intraocular Pressure 1 Day Postoperatively
0
5
10
15
20
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
mm
Hg
Percent ECC Loss by Cataract Grade: Preop to 2 Month Postop
-10
0
10
20
30
40
1 2 3 4
Cataract Grade
Per
cen
t
DisCoVisc DuoVisc BioVisc Healon5 Amvisc Plus
Percent ECC Loss by Cataract Grade: Preop to 2 Month Postop
0.00
10.00
20.00
30.00
40.00
1 2 3 4
Cataract Grade
Per
cen
t
DisCoVisc DuoVisc BioVisc Healon5 Amvisc Plus
Note: No statistical difference exists (p = 0.5489) in % ECC loss by cataract grade.
(p = 0.5489)
2 Months Postop: % ECC Loss by CDE Level (All OVDs)
0
10
20
30
40
50
<5.0 >5 to <10 >10 to <15 >15 to <20 >20
CDE Range
% E
CC
Lo
ss
2 Month Postop: % ECC Loss by CDE Level
0
10
20
30
40
50
<5.0 >5 to <10 >10 to <15 >15 to <20 >20
CDE Range
EC
C L
oss
DisCoVisc DuoVisc BioVisc Healon5 AmviscPlus
MCTo ECC: MCTo ECC: 8% 8% < ToSt / < ToSt / 16% 16% < Trphaco< TrphacoMCTo Pach: >< ToSt / MCTo Pach: >< ToSt / 16% 16% < Trphaco< Trphaco
9.6% 8.9%8.1%
5.2%4.0% 4.1%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
LONGITUD. (106 Surgeries)
TORSIONAL (102 Surgeries)
TORS'L+ULTRA(102 Surgeries)
Patient Outcome Parameter Comparison
Pachymetry (% increase inthickness)Endothelium CellLoss (% cell loss)
TORSIONAL VS LINEARTORSIONAL VS LINEAR
Literature : Less Ultrasound energy and BSS used Literature : Less Ultrasound energy and BSS used during phaco diminishes the risk for endothelial cell during phaco diminishes the risk for endothelial cell loss and corneal burnsloss and corneal burns
Ernest P, Rhem M, Mc Dermott M et al. Phacoemulsification conditions resulting in thermal wound injury. J Cataract Refract Surg 2001; 27:1829-1839
DeBry P, Olson RJ, Candall AS. Comparison of energy required for phaco chop and divide and conquer phacoemulsification. J Cataract Refract Surg 1998; 24:689-692
Dick HB, Kohen T, Jacobi FK, et al. Long term endothelial cell loss folowing phacoemulsification through a temporal clear corneal incision. J. Cataract Refract Surg 1996; 22:63-71