California's Central Valley is home to about five Kaiser-affiliated hospitals, offering emergency and other medical services 24 hours a day, seven cslifornia a week. West Lancaster, CA Driving directions References Kaiser Permanente: Quick Facts. Written by Max Stirner. Max Stirner is a New York-based writer and editor with over a decade of experience. Richmond, CA 1 0.
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|Nuance transcription services class action lawsuit||I used the yellow-tinted cohesive to flatten the capsule, and I was able to create a round, well-centered capsulorrhexis, even in the young, elastic capsules of the pig eyes. In: Viscoelastics alcon D, Stegmann R, editors. Click the following article allows me to use a cohesive OVD viscoelastics alcon space maintenance and compartmentalization, as well as a dispersive OVD for coating and protection. Once the nucleus has been removed and the cortex cleaned from the capsular bag, it is time to insert the IOL. Click Here to Manage Email Alerts. Twinvisc combines two viscoelastic solutions in a single syringe, one dispersive and one cohesive, with complementary and synergistic properties, separated by a bypass stopper system.|
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Getting Surgeons to Switch. If you are interested in persuading your surgeons to consider changing the viscoelastic they're using in favor of one that costs less, you have to educate and wait, say two surgery centers that have done it. First, "I got pricing so I could show [the surgeons] the difference," says Ms.
The surgeons agreed to "give it a shot" and, at the very next board meeting, "four of five agreed to switch" permanently, says Ms. Mary Ann Greenwald, RN, an OR circulator for Eye Centers of Florida in Fort Myers, says when physicians start doing cataract surgery at her center, they usually request the viscoelastic they're used to - for this reason, Ms. Greenwald keeps a small supply of all viscoelastics on hand. She gradually introduces the facility viscoelastic of choice. Greenwald asks her surgeons to try it, then asks that they use the viscoelastic a bit more often to get used to it - and she shows them the price differential.
He likes the idea of a viscoelastic that has properties of both a cohesive and a dispersive; he thinks it's more convenient than using two separate products. Tharp calls it his "workhorse viscoelastic," and endorses it "for routine cases when I want them to stay routine. Amvisc, also one of the most popular non-Alcon viscoelastics, is a cohesive viscoelastic touted by the company as "excellent for chamber maintenance," with "complete removal at the end of the case ' quickly and easily accomplished.
Street Prices at a Glance. Most of the viscoelastic makers contacted for this article would not provide list prices for their products. The chart below represents rough "street" prices for selected vial sizes for viscoelastics available today, arranged alphabetically. The prices were drawn from figures given by five surgery centers in different regions of the United States.
Your pricing may vary. Healon, Healon GV and Healon 5 According to Pharmacia, Healon 5 is a "viscoadaptive," in that it acts as a cohesive and a dispersive, adapting throughout surgery Fig. It's latex free, and is moderately priced. And because it stays in the eye, you tend to use a little less. The knock on Healon 5 is its thickness; Robert Osher, MD, the medical director emeritus of the Cincinnati Eye Institute in Montgomery, Ohio, recommends keeping aspiration and vacuum low to adjust for this property.
To remove the product, simply turn up the two parameters, and Healon 5 can be "easily, completely, quickly and safely removed. Osher, a professor of ophthalmology at the University of Cincinnati, recently studied the efficacy of Healon 5 in consecutive cataract procedures. Healon is a cohesive comprised of long molecular chains that, the company says, at rest, create space and absorb shock.
However, at high shear rates, Healon becomes very fluid, facilitating injection of the IOL. Healon is much less viscous than Healon GV, a high-molecular-weight cohesive. Pharmacia recommends Healon GV for foldable IOL surgery and touts is clarity, space creation, control and endothelial protection.
For this reason, Dr. Hunkeler uses CoEase Fig. CoEase is a cohesive viscoelastic for use in the anterior and posterior chambers that is meant to maintain anterior chamber depth and visibility, and of course, to protect corneal endothelium. VisThesia Combines Two Elements. Currently available in Europe is Ciba Vision's new VisThesia - a cohesive viscoelastic that contains anesthetic compound. VisThesia is packaged with both topical and intracameral components with separate percentages of sodium hyaluronate and lidocaine hydrochloride.
Ciba says intracameral injection has been shown to increase patient comfort over the use of a topical anesthetic alone. The surface tension of sodium hyaluronate is less; hence it has a better coating ability. This is a viscoelastic property wherein it changes from a supraviscous state at a low shear rate to a fracturable pseudo-dispersive at a higher shear rate. Healon 5 has high viscoadaptability and has revolutionized the application of viscoelastics.
Cohesiveness is a property by which molecules of viscoelastics adhere to one another and form a clump. Higher the molecular weight, higher the surface tension, and higher the pseudo-plasticity, higher is the cohesiveness of a viscoelastic. Sodium hyaluronate is more cohesive than HPMC and is challenging to aspirate from the anterior chamber during surgery. Dispersive viscoelastics have less tendency to adhere to each other. Viscoelastics with low molecular weight, low surface tension, and low pseudo-plasticity are dispersive viscoelastics.
Higher the molecular weight of a viscoelastic, the higher the coatability. More negatively charged sodium hyaluronate and chondroitin sulfate complex has a greater affinity for positively charged instruments, tissues, and implants.
Viscoelastics form an essential component for every step of all types of cataract surgery, whether it is phacoemulsification, manual small incision cataract surgery MSICS , extracapsular cataract extraction ECCE , or intracapsular cataract extraction ICCE. Viscoelastics assist in capsulorhexis, hydrodissection, nucleus prolapse and manipulation, trenching and emulsification of nucleus, IOL implantation, and they also coat the endothelium and prevent corneal damage.
The primary function of OVDs is to form the anterior chamber by replacing aqueous humor. For capsulorhexis, a viscoelastic should have high viscosity, high transparency, good capsular flap control for a spatula effect, and high molecular weight at zero shear rate and must maintain the anterior chamber.
The pediatric capsule is highly elastic; hence high density viscoelastic like Healon GV is viscoelastic of choice. In the case of posterior capsular rent during irrigation and aspiration, a dispersive viscoelastic is used to plug the defect. In trabeculectomy, hyaluronic acid is the viscoelastic of choice.
It helps to prevent endothelial trauma maintain the anterior chamber depth. Some surgeons leave viscoelastic in the anterior chamber to prevent postoperative hypotony and retino-choroidal folds.
Viscoelastic can also be injected subconjunctivally for bleb formation. In viscocanalostomy surgery, viscoelastic is used to open the Schlemm canal. Hyaluronic acid containing viscoelastics is used for viscocanalostomy as they have high pseudo-plasticity and high viscosity.
Due to these properties, the viscoelastic can be injected into the Schlemm canal through a small needle, and they help maintain the space. In penetrating keratoplasty, the viscoelastic helps maintain the anterior chamber before trephination, provides good support for perfect trephination, helps in the protection of intraocular structures, tamponade the vitreous, and coat the corneal donor button while suturing to prevent endothelial damage.
Viscoelastics also play a significant role in deep anterior lamellar keratoplasty DALK for layer by layer removal of the host cornea and for exposing the Descemet membrane DM during surgery. In femtosecond laser application of cornea, viscoelastics help to protect the corneal endothelium. Viscoelastic can be mixed with lidocaine, and the mixture is used for intracameral anesthesia. This treatment modality is labeled as viscoanaethesia.
Viscoelastic helps to prolong the effect of lidocaine. Viscoelastic specially cohesives help to dilate the pupil during the surgery. In small pupil cases, it helps in viscomydriasis. Intraoperative Floppy Iris Syndrome IFIS is a known complication in patients treated for prostatic hyperplasia with alpha-adrenergic blockers.
Viscoadaptive viscoelastics are helpful in such a scenario to dilate and stabilize the pupil. This also helps to prevent iris prolapse. The membranous adhesions during retinal surgery can be safely separated and excised with the help of viscoelastics.
It also helps to release the traction. Sodium hyaluronate is one of the most commonly used viscoelastic during retinal surgeries. In pediatric cataract, viscoelastic help in all the routine steps of cataract surgery. In strabismus, surgery helps in suture adjustment with less force, helps to coat the muscle, and decreases scar formation in the muscular tissues.
It is a salt derivative of hyaluronic acid and is present in the connective tissue of bacteria and humans. In homo sapiens, it is found in skin, synovial fluid, and vitreous humor. Sodium hyaluronate was first extracted from the vitreous humor of cows, and Mayer and Palmer named it because it is derived from hyaloids and contains uronic acid.
The commercially available formulation is extracted from rooster coombs or streptococcal bacterial culture. Sodium hyaluronate is a long-chain mucopolysaccharide chain with a molecular weight of 2. The viscosity ranges from to centipoise with a half-life of 1 day in aqueous and three days in vitreous.
The characteristic properties of sodium hyaluronate are sterile, noninflammatory, non-toxic, nonantigenic, and nonpyrogenic. The physical and chemical characteristics of chondroitin sulfate are similar to sodium hyaluronate. The structure of chondroitin sulfate differs by a sulfated group and double negative charge for every subunit. Commercially available choroid tin sulfate is derived from shark cartilage.
It is found in the cornea as one of the three major mucopolysaccharides. It is a low viscosity preparation and not a space maintainer; instead helps in surface protection. It is more viscous and has a better coating ability. HPMC is cellulose-derived and extracted from plant fibers like cotton and wood.
It is not found in animal tissues. The viscosity of HPMC is to centipoise. It is less viscous and lacks the properties of a complete viscoelastic. The molecular weight is ; pH is 7. It is sterilized by autoclaving and has a shelf life of 2 years at room temperature. The optic is pushed and angled to one side, and viscoelastic is removed from under the optic.
A similar maneuver is performed on the contralateral side to remove the remaining viscoelastic. The irrigation and aspiration tip can be moved back and forth to assist the removal of viscoelastic compartments. After IOL implantation, the IOL can be dialed degrees to remove the remaining residual viscoelastic at the equator. If the viscoelastic is not thoroughly washed intraoperatively from the anterior chamber and capsular bag, it will result in a post-operative IOP spike, usually within 6 to 24 hours.
The IOP increases because the trabecular meshwork is clogged, and there is mechanical resistance with large particles of the OVD. In most cases, it resolves spontaneously after 72 hours, but if the IOP rise is persistent, it should be managed with antiglaucoma medications. Capsular block syndrome CBS or capsular block distention syndrome has been reported after viscoelastic use.
It refers to the collection of fluid or viscoelastic in the capsular bag behind the nucleus or IOL. The nucleus or IOL is pushed forward, blocking the anterior capsular opening. CBS has been classified as. Intraoperative - Due to collection of balanced salt solution in the capsular bag during hydrodissection. Early post-operative - Due to the viscoelastic accumulation in the capsular bag at the end of surgery. Late post-operative - High-density viscoelastic accumulation in the capsular bag like hyaluronic acid in the capsular bag.
Due to high viscous property and negative electrostatic charge, the red blood and inflammatory cells may clump and remain suspended in the anterior chamber. This resolves spontaneously within three days. Sometimes the hyphema or the blood clot may get trapped within the vitreous phase and OVD in the anterior chamber mimicking vitreous hemorrhage.
This complication has also been reported after OVD instillation. This is also have been reported after OVD use. It occurs due to residues of viscoelastic solution over the IOL surface.
The deposits take the pattern of a fern or an amorphous deposit. The IOL calcification mandates an explantation or an exchange. This has been reported with chondroitin sulfate-containing OVD. A small risk of hypersensitivity exists with OVD as sodium hyaluronate is extracted from rooster coombs or streptococcal bacterial culture containing proteins. In the soft shell technique, a dispersive viscoelastic is injected in the anterior chamber forming a small clump on the anterior lens surface.
Next, a cohesive viscoelastic is injected below the dispersive on the posterior surface, which pushes the dispersive upwards on the back surface of the cornea, thus protecting the endothelial cells. This technique is helpful during phacoemulsification and irrigation aspiration as it protects the corneal endothelium from trauma due to ultrasound energy and excessive fluid turbulence irrigation. The softshell technique is beneficial in Fuch's endothelial dystrophy, congenital hereditary endothelial dystrophy, extreme crocodile shagreen cases, and denser cataracts Brown and Intumescent cataract.
In this technique, a viscoadaptive viscoelastic is first injected in the anterior chamber, and then balance salt solution BSS is filled beneath the viscoadaptive viscoelastic.
The ultimate softshell technique was introduced to cut down the cost due to the soft shell technique since it employed two different viscoelastics. The viscoelastic in this technique plug the incisional wound, while BSS over the anterior lens surface helps to reduce the resistance while performing surgical maneuvers.
This technique first injects a dispersive viscoelastic in the anterior chamber above the lens surface. Then a viscoadaptive viscoelastic is injected below the dispersive to float the dispersive to coat and protect the endothelium. Viscoelastic are substances with dual properties having a viscosity of a fluid and elasticity of a gel or a solid.
They are commonly employed in all kinds of ophthalmic surgical interventions. The nurses, mid-level ophthalmic personnel, pharmacist, allied health, and OT store staff have a crucial role in arranging the viscoelastics during the surgical intervention.
The ophthalmic surgeon should make judicious and timely use of viscoelastics during surgical intervention with no trauma to the ocular structures. It is the responsibility of the operating surgeon to ensure that the viscoelastic is washed thoroughly from the eye at the end of the surgical procedure. In case of any ocular complication of viscoelastic the surgeon and the paramedical staff also has to play an essential role in prompt and meticulous treatment.
The nurses also play an essential role in ensuring the availability and maintaining the sterility of commonly employed viscoelastics. In addition, the allied health and interprofessional team play a key role in arranging the required viscoelastics and ensuring sterility. The nursing, allied health, and interprofessional team also play a crucial role in monitoring the patient outcome and ensuring the availability of viscoelastics.
You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Viscoelastics Kirandeep Kaur ; Bharat Gurnani. Affiliations 1 Aravind Eye Hospital, Pondicherry. Continuing Education Activity Viscoelastic are substances with dual properties having a fluid's viscosity and elasticity of a gel or a solid.
Introduction Viscoelastics are also known as ophthalmic viscosurgical devices. Should have an ability of retention under pressure, should be highly cohesive with high viscosity.
Should be liquid enough so that it can be injected through a small-bore cannula . Table S. No Type. No Viscoelastic. Indications Cataract Surgery Viscoelastics form an essential component for every step of all types of cataract surgery, whether it is phacoemulsification, manual small incision cataract surgery MSICS , extracapsular cataract extraction ECCE , or intracapsular cataract extraction ICCE. No Surgical step. Preparation Sodium Hyaluronate It is a salt derivative of hyaluronic acid and is present in the connective tissue of bacteria and humans.
Chondroitin Sulphate and Sodium Hyaluronate It is more viscous and has a better coating ability. Complications The various complications associated with viscoelastics are Secondary Glaucoma If the viscoelastic is not thoroughly washed intraoperatively from the anterior chamber and capsular bag, it will result in a post-operative IOP spike, usually within 6 to 24 hours. CBS has been classified as Intraoperative - Due to collection of balanced salt solution in the capsular bag during hydrodissection.
Clinical Significance Techniques Helpful During Surgery Soft Shell Technique In the soft shell technique, a dispersive viscoelastic is injected in the anterior chamber forming a small clump on the anterior lens surface. Enhancing Healthcare Team Outcomes Viscoelastic are substances with dual properties having a viscosity of a fluid and elasticity of a gel or a solid.
Nursing, Allied Health, and Interprofessional Team Interventions The nurses also play an essential role in ensuring the availability and maintaining the sterility of commonly employed viscoelastics.