0710crsteuro supp zeiss bbmctoday.net/crstodayeurope/2011/07/digital... · phthalmic viscosurgical...

Supplement to July/August 2010

Sponsored by an educational grant from Carl Zeiss Meditec

forEngineered Simplicity

VISTHESIA®: The uniquecombination of OVD andancillary anesthesia.

forEngineered Simplicity

2 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERT TODAY EUROPE I JULY/AUGUST 2010

ENGINEERED FOR SIMPLICITY

The unique alliance of ophthalmic viscosurgical device and ancillary anesthetic.

VISTHESIA

Ophthalmic viscosurgical devices (OVDs) are essentialto the success of today’s ophthalmic procedures. Incataract surgery, injection of these OVDs protects

intraocular tissue from physical trauma and helps tomaintain the shape of ocular structures during the surgicalprocedure. There is an abundance of OVD products on themarket; however, there is just one that unites the benefitsof the OVD with an ancillary anesthetic.

VISTHESIA 1.0% and 1.5% (Carl Zeiss Meditec) areophthalmic viscoanesthetic surgical devices consisting of twocomponents: VISTHESIA topical, an OVD with lidocaine fortopical application to maintain hydration of the cornealsurface and for topical anesthesia, and VISTHESIA 1.0% or1.5% intracameral, an OVD with lidocaine to protect intraocular tissue during the traumatic steps of phacoemulsification that also helps maintain the shape ofthe anterior chamber (Figure 1).

Combining an OVD with an anesthetic is compellingbecause it improves patient comfort, which in turn providesa more relaxed atmosphere in the operating room.VISTHESIA is very fitting for routine cataract surgery and itis also an excellent OVD for surgeons who are introducingcataract surgery under topical anesthesia into their clinic.

PROCEDUREThe patient is prepared for surgery by applying

VISTHESIA topical to the surface of the eye, and theOVD spreads over the entire eye as the patient blinks.

Once the surgicalprocedure starts,VISTHESIAintracameral, either1.0% or 1.5%, dependingon the surgeon’spreference, is injectedinto the anteriorchamber with a 27-gauge cannula, therebycreating andmaintaining a deepanterior chamber.Additional VISTHESIAintracameral can beused as necessary. Priorto wound closure,VISTHESIA intracameralshould be completely

removed using a standard irrigation and aspirationtechnique.

CONCLUSIONVISTHESIA 1.0% or 1.5% provides a two-step solution for

corneal protection pre- and intraoperatively. The ancillaryanesthetic lidocaine contained in both components ensurespatient comfort pre- and intraoperatively. VISTHESIA hasbeen used for the benefit of patients and surgeons since

2002, with more than 3 millioncataract surgery proceduresperformed with this OVD. Theopportunity for surgeons to combine topical and intracameralanesthesia with an OVD offers asignificant improvement in cataractsurgical techniques. Its use in retinalsurgery has also been explored off-label.

In the following pages, thisproduct is discussed in detail byEkkehard Fabian, MD; Gerd U.Auffarth, MD; Carlos RuizLapuente, MD; Joseph Colin, MD;and Karin Wallentén, MD, PhD, allof whom use VISTHESIA regularly.

VISTHESIA is the next logicalstep in the evolution of cataractsurgery.

Figure 1. VISTHESIA 1.5%

intracameral syringe and topical

ampoules.

VISTHESIA® 1.0% VISTHESIA® 1.5%Origin Bacterial Fermentation Bacterial FermentationSubstance Sodium Hyaluronate Sodium Hyaluronate

Concentration topical ampoules 0.3% NaHa 2% lidocaine 0.3% NaHa 2% lidocaine

Volume topical ampoule 0.3 mL 0.3 mL

Concentration intracameral syringe 1% NaHa 1% lidocaine 1.5% NaHa 1% lidocaine

Volume intracameral syringe 0.8 mL 0.8 mL

pH 7.0-7.6 7.0-7.6Osmolality (mOsmol/kg) 280-330 280-330

Molecular weight (Da) 2,500,000 2,500,000

Pseudoplasticity index 46 105

Zero-shear viscosity (mPa.s) 100,000 220,000

Recommended cannula 27-gauge 27-gauge

Storage 2-8ºC 2-8ºCPackaging Box of 1 syringe and

2 topical ampoulesBox of 1 syringe and 2 topical ampoules

JULY/AUGUST 2010 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERT TODAY EUROPE I 3


VISTHESIA is beneficial for workflow and patient satisfaction.

BY EKKEHARD FABIAN, MD

Visco Anesthesia andCataract Surgery

The first form of anesthesia in cataract surgery, topicalcocaine, was introduced in 1883. Topical anesthesia withnew agents is again popular today; it is often used in combination with intracameral application of lidocaine.Anesthetics can also be administered as peribulbar orretrobulbar injections. Today in Germany, approximately33% of cataract procedures are done under topical anesthesia, but the majority of surgeries are still underinjectable or general anesthesia.

Each anesthetic has unique chemical characteristics,points of origin, duration, and toxicity; surgeonsshould consider such qualities before choosing ananesthesia product. For instance, topical anesthesiahas the shortest duration of effect.

The majority of patients can be operated on under topical anesthesia, assuming that the surgeon performs

small incision cataract surgery. I recommend that the surgeon be comfortable with a temporal approach and performing a continuous curvilinear capsulorrhexis.Additionally, patients should be informed preoperativelythat they will be under topical anesthesia. VISTHESIA (CarlZeiss Meditec), an ophthalmic viscosurgical device (OVD)that includes 1% lidocaine, provides additional comfort topatients under topical anesthesia.

WORKFLOWI started using VISTHESIA in 2002 because of its

Figure 1. (A-F) Injection of an IOL with VISTHESIA. (A) The foldable IOL is injected into the capsular bag, (B, C) unfolds, and (D) is

rotated into place, with the second haptic placed in the capsular bag. (E) VISTHESIA is aspirated from behind the IOL. (F) The IOL

is centered and placed in the capsular bag.

A B

E F

C D

Some patients come to our centerspecifically because we use VISTHESIA.

perceived benefits in the operating room. It is cheaperthan general anesthesia and does not need additionalintracameral lidocaine, thus the biggest advantage ofVISTHESIA is its time-saving benefit. With topical andvisco anesthesia, there is no need for oculopression.The lights from the microscope in the first 30 secondsmay be disturbing, but the patient quickly adapts. Thepatient may detect more IOP changes under topicalanesthesia compared with other anesthetics. However,the ancillary effect of the lidocaine included inVISTHESIA intracameral avoids these uncomfortablesituations. Therefore, I especially use intracamerallidocaine in myopic (large) eyes.

There are some parameters to take into account withthe use of topical and visco anesthesia, including mobilityof the eye, a slightly dry cornea, patient cooperation, andneed to readjust the microscope. However, these areminor adaptations that can be easily overcome by anysurgeon. Still today, some patients come to our centerspecifically because we use topical and visco anesthesia. Iuse this product in the majority of the cases that I perform.

PROCEDUREWithin 45 to 60 minutes before surgery, the patient's

pupil is dilated, and antibiotics and nonsteroidal anti-inflammatory eye drops are applied up to four times.Once the patient enters the operating room, he firstreceives the VISTHESIA topical together with lidocaine.

It only takes one drop of topical anesthesia before thepatient no longer feels any pain; however, placingVISTHESIA topical on the eye two or three times willreduce the dry eye during the operation. Figure 1depicts the injection and aspiration of VISTHESIA.

CONCLUSION VISTHESIA is the only OVD on the market to have

anesthetic included in the OVD. Using this in our institutionhas been very beneficial for me in terms of workflow andpatient satisfaction. Two of my colleagues were in thepractice of using topical anesthesia in combination withlidocaine in approximately 90% of procedures. With theintroduction of VISTHESIA intracameral, surgeons havereduced their use of lidocaine nearly by 100%. Now theyalso save time in the operating room and have seen thebenefits in patient satisfaction.

Using a combined OVD and anesthesia product hasbeen even better than I expected, with no additionalcomplications when used in low concentrations andquieter eyes. Because VISTHESIA is a time-savingsolution and helps regulate workflow, it is thereforecost-effective. It should be routinely used in alloperating rooms today.

Ekkehard Fabian, MD, is in private practice in theAugenCentrum, Rosenheim, Germany, with anintegrated ASC. Professor Fabian states that he is aconsultant to Abbott Medical Optics Inc. and Carl ZeissMeditec. He may be reached at e-mail:[email protected].



Using VISTHESIA in our institution hasbeen very beneficial for me in terms of

workflow and patient satisfaction.

VISTHESIA should be routinely used inall operating rooms today.



Study compared the use of VISTHESIA 1.5% and Z-HYALIN plus.

BY GERD U. AUFFARTH, MD

Trend Toward Higher PatientSatisfaction With a ViscoAnesthetic OVD

Recently, I performed an assessment of patientsatisfaction after cataract surgery with topicalanesthesia alone versus with VISTHESIA 1.5% (Carl

Zeiss Meditec), an ophthalmic viscosurgical device(OVD) combined with an anesthetic (lidocaine). Notonly were patient satisfaction levels higher withVISTHESIA 1.5%, but clinically I experienced anenhancement in workflow.

The prospective, randomized study was designed todetermine the level of intraoperative comfort with VISTHESIA1.5%, which is the same OVD formulation asZ-HYALIN plus (Carl Zeiss Meditec) except for theaddition of 1% lidocaine. In this double-blind study, oneeye was randomized to VISTHESIA 1.5% and the felloweye to Z-HYALIN plus. Both OVDs were distributed usingthe same style syringe, and all cataracts were of similardensities, as measured preoperatively by the Pentacam(Oculus Optikgeräte GmbH, Wetzlar, Germany) andScheimpflug camera.

Some of the parameters we studied includedendothelial cell count, functional results, and pain scoreon a visual analog scale (0 to 10). The surgical set-up forall eyes was standard clear corneal cataract surgeryunder topical anesthesia (xylonest 2% gel). Duringsurgery, the anterior chamber was filled with eitherVISTHESIA 1.5% or Z-HYALIN plus. After capsulorrhexisformation, phacoemulsification, and irrigation andaspiration, VISTHESIA 1.5% or Z-HYALIN plus was againinjected to fill the capsular bag before IOL implantation.After the IOL was positioned, the OVD was thoroughlyremoved, and incisions were hydrated.

RESULTSThe mean preoperative endothelial cell count in both

groups was 2,200 cells/mm2. Figure 1 demonstrates aslight change in cell count from preoperative to 3months postoperative (2,450 vs 2,400 cells/mm2) in asingle patient—a nonstatistically significant difference.This trend was seen in the entire patient population,regardless of the OVD used (Figure 2). At 3 months,there was exactly 3.5% endothelial cell loss in the VISTHESIA 1.5% and Z-HYALIN plus groups, whereas

Figure 1. (A) Pre- and (B) 3-month postoperative endothelial

cell counts in eyes with VISTHESIA 1.5%.

A

B

Patients prefer, and had less pain with,VISTHESIA 1.5%.

older studies have between 7% and 9% endothelial cellloss. This is mostly due to the minimally invasivecataract surgical techniques used today.

Visual acuity in both groups developed normally after 3months, with most patients achieving an acuity of 0.8. On ascale from 0 to 10, pain was minimal for both groups, 0.88for the Z-HYALIN plus and 0.76 for the VISTHESIA 1.5%group. There was one outlier in the VISTHESIA 1.5% groupwho scored his pain as a 7. If this patient was removed fromthe data, there is a more significant difference in pain scores(0.57 for VISTHESIA 1.5%); however, for the purposes of ourstudy this patient’s pain score was included.

We also found a correlation between the pain score andthe postoperative visual acuity: The better the visual acuity,the more satisfied patients are, and the less they complainabout the associated pain. With VISTHESIA 1.5%, there wasa clear correlation; however, it was not as clear with Z-HYALIN plus, showing that other factors influence thepatient’s perception of pain. We asked the 61 patientsenrolled in the study, “What eye had less pain duringsurgery, your right or left?” A total of 63% said they hadmore pain in the eye that received Z-HYALIN plus (Figure 3).This intraindividual comparison is an indirect indicationthat patients prefer, and had less pain with, VISTHESIA 1.5%.

FROM ROUTINE TO COMPLICATED CASESThe preference for VISTHESIA 1.5% is apparent in routine

cataract cases, but I also recommend its use in complicatedcases such as intraoperative floppy iris syndrome or other irispathologies. I have found that when you touch the iris severaltimes and use iris retractors, VISTHESIA 1.5% is the bestoption. This is also true for eyes with small pupils orpseudoexfoliation, because surgery takes longer. Prolongedsurgical time can be perceived as painful for the patient.

I also think that VISTHESIA 1.5% is a wise choice for othercomplicated cataract procedures, such as extracapsularcataract extraction and other techniques that requireincreased manipulations of the eye. In such situations, acombination of topical anesthesia and VISTHESIA 1.5% wouldbe very helpful. Another scenario where VISTHESIA 1.5% is theoptimal choice is for inexperienced surgeons and residentswho need more time to complete a cataract procedure. Inthese situations, topical anesthesia alone may not beeffective enough. VISTHESIA 1.5% is a unique product, withan abundant amount of possibilities for its use. The moreyou think about it, the more you realize that it is aninteresting choice for multiple indications.

CONCLUSIONIn general, the more quiet the patient and the less pain he

perceives, the shorter the procedure time. Saving 3 or 5 secondsin a 10-minute procedure does not matter, but the patient’slevel of comfort does. For me, the big advantage of usingVISTHESIA 1.5% is that the patient is more relaxed, whichmeans that he is not squeezing his eye or moving his head. Thismakes the surgery safer. I perform cataract surgery in a lot ofcomplicated cases, as many of my patients havepseudoexfoliation. I use VISTHESIA 1.5% a lot. I like to think ofOVDs as instruments, and I choose the best OVD dependingon the specific environment. In many cases, this is VISTHESIA 1.5%. ■

Gerd U. Auffarth, MD, is Acting Chairman ofthe Department of Ophthalmology, University ofHeidelberg, Germany. Professor Auffarth statesthat he has no financial interest in the productsor companies mentioned. He may be reached ate-mail: [email protected].



Figure 2. Pre- and 3-month postoperative corneal

endothelial cell count with VISTHESIA 1.5% and

Z-HYALIN plus.

Figure 3. Intraindividual comparison of paired data sets on

pain perception during cataract surgery with VISTHESIA 1.5%

and Z-HYALIN plus.

The big advantage of using VISTHESIA 1.5%is that patients are more relaxed.

I choose the best OVD depending onthe specific environment. In many

cases, this is VISTHESIA 1.5%.



This OVD with lidocaine is perfect for vitrectomy and routine cataract cases.

BY CARLOS RUIZ LAPUENTE, MD

VISTHESIA in a High-Volume Clinic

After using VISTHESIA (Carl Zeiss Meditec) in morethan 20,000 cataract and vitrectomy surgeries, Ihave devised three scenarios in which its use is

crucial: (1) fast track or large-volume waiting lists withvariable pupillary dilation and sedation condition,resulting in eyes with poorly dilated pupils, (2) combinedprocedures (Figure 1), and (3) eyes with myopia. In thesesituations, I undoubtedly trust the additional anestheticproperties of this OVD to keep my patients comfortable.

In our hospital, we perform more than 7,000procedures with VISTHESIA each year. In a high-volumesetting such as ours, patient safety and comfort is thefirst priority, and any product or practice that enhancespatient comfort will enhance the workflow. In additionto using VISTHESIA in the scenarios mentioned herein,I also believe in its use for routine cataract surgerywhenever possible.

PROTOCOL: MANDATORY USEWe must consider the risk of onsite manipulations or

dilutions of direct intracameral lidocaine, because of thepotential for infection and endothelial damage. Wheneverthe pupil is the source for potential discomfort, theaddition of lidocaine 1% is mandatory; its application inthe form of VISTHESIA is the only way to add lidocaine 1%without causing any hazardous manipulations.

Scenario No. 1: Fast track settings/poorly dilatedpupils. Whenever you have suboptimal dilation,VISTHESIA helps to guarantee that the patient willremain pain-free throughout the duration of theprocedure. In routine cataract surgery, especially in large-volume settings with a fast track, you can never ensurethat patients are properly dilated. The pupilary size mightbe in the decreased part of the curve when you finallyget the patient into the operating room, which can inreturn decrease patient comfort. Clinically, the ideal

scenario is that the surgeon has only three to five cases toperform in a very controlled environment; however, thisis never going to happen in a large-volume setting.

Scenario No. 2: Combined procedures. VISTHESIA isalso beneficial whenever you have to manipulate the iris orconstrict the pupil after the procedure. One example iscombined cataract and glaucoma surgery. In this situation,it is important to use VISTHESIA after IOL implantationbecause constricting the pupil can be uncomfortable forthe patient.

At the end of some procedures, the surgeon mayneed to block excess outflow to avoid the earlycomplication of postoperative hypotony (Figure 2).VISTHESIA is a great tool for subconjunctival injections,because the surgeon can control the surgical situationknowing that the patient is pain-free.

Scenario No. 3: Myopic eyes. In the presence of a verywide or large anterior chamber, it is common for pressureto build over the root of the iris with any manipulation.VISTHESIA provides additional stability and control so thatyou can confidently proceed with the necessarymanipulations of the eye. Additionally, it is useful to applyVISTHESIA if and when intraoperative floppy iris syndromeis present, as with any other source for iris fluctuation.

We perform more than 7,000 procedures with VISTHESIA each year.

Figure 1. Subconjunctival VISTHESIA for combined or

vitreoretinal procedures and maneuvers.

OTHER CASES FOR VISTHESIAThere are a number of significant cases in which the

use of VISTHESIA is almost unavoidable, for examplewhenever you perform a planned iridectomy. Thealternative would be an infusion of lidocaine within theanterior chamber. The benefit of using VISTHESIA is thatit coats the iris during the entire procedure; there is noneed to reapply VISTHESIA, whereas the infusions oflidocaine must continually be renewed. Furthermore, itspreparation is more prone to changes or contamination.

I typically use VISTHESIA any time I insert a MalyuginRing (MicroSurgical Technology, Redmond, Washington),such as with pupilary enlargement and pupilloplasties incases of uveitis and long-standing glaucoma treatments. I

also use VISTHESIA in any cases of lens exchange orretrieval, with anterior chamber lens implantation, andwhenever I perform surgery in the posterior segmentwith the potential for anterior uveal discomfort.

Another indication is what we call topical vitrectomy,which in fact combines topical and subconjunctivalvitrectomy. Typically, vitrectomy is a subconjunctivalprocedure, but the viscoelastic properties of VISTHESIAcontrol the egress of the vitreous, leaving no room forcontamination or endophthalmitis. When performingvitrectomy, topical anesthesia is applied first, followedby subconjunctival injection of VISTHESIA to achieve adouble benefit. Additionally, the coating provided byVISTHESIA topical ensures a good seal between thecornea and the contact lens; VISTHESIA intracameral

can also be injected into the anterior chamberdepending on the specific surgical procedure.

PATIENT COMFORTUsing VISTHESIA in any vitrectomy procedure is

beneficial because the patient is very comfortable. You canrequest the patient to look up or down, allowing you toreach areas in the eye that you may not possibly reachunder other forms of anesthesia or without assistance fromsurgical assistants. Additionally, VISTHESIA allows scleralindentation without pain. The only limitation for the use ofVISTHESIA in vitrectomies is a scarred conjunctiva, whichwould not allow the bleb to be configured for the entry ofsurgical trocars, cannulas, or other instruments.

I can save approximately 9 minutes per vitrectomycase using VISTHESIA compared with other forms ofanesthesia. However, in routine cataract surgery, itsbenefits are more about patient comfort. VISTHESIAprovides the security of knowing the patient has maximalcomfort in spite of suboptimal conditions, such as pupilsize. Additionally, change of surgical plans may occur or acomplication may arise, and you cannot afford to put thepatient in the position of possibly feeling pain.

CONCLUSIONIn my opinion, it is better to control pain with one

product versus multiple products. VISTHESIA has been agreat product to add to my operating room. Itsviscoelastic capacity, along with the anesthetic effect oflidocaine, produces less likelihood of contamination.Furthermore, many surgeons have had at least one badexperience with a pharmacist’s preparation of intraocularsolutions. Finally, the surgeon is ultimately responsible forthe preparation of anesthesia and the patient’s comfort.Patient comfort is the surgeon’s security. ■

* Editor’s Note: VISTHESIA 1.5% and VISTHESIA 1.0% are notCE marked for use in vitreoretinal surgery.

* Editor’s Note: VISTHESIA 1.5% and VISTHESIA 1.0% are notCE marked for use in glaucoma surgery.

* Editor’s Note: VISTHESIA intracameral should becompletely removed at the end of the surgery.

Carlos Ruiz Lapuente, MD, practices in theDepartment of Ophthalmology, Virgen del RocíoHospital, Seville, Spain. Dr. Lapuente states thathe has no financial interest in the products orcompanies mentioned. He may be reached at e-mail: [email protected].



Figure 2. The use of VISTHESIA avoids vitreous incarceration

and postoperative hypotony.

VISTHESIA provides the security ofknowing the patient has maximal

comfort.

Patient comfort is the surgeon’s security.



A revolution for cataract surgery.

BY JOSEPH COLIN, MD

Recent Developments inTopical Anesthesia

The development of topical anesthesia for use incataract surgery is one of the most innovativeconcepts of modern surgical techniques. For me,

gone are the days of general anesthesia and anestheticinjections. Topical is my preference today. Somesurgeons continue to rely on these other methods toensure patient comfort throughout the procedure;however, the number is decreasing as more surgeonscome to understand the apparent benefits of topicalapplications: the shorter preparation and applicationtimes; the eliminated risk of retrobulbar hemorrhageor bulbar trauma related to injectable anesthesia; andthe uninterrupted vision for patients. Additionally,topical anesthesia is perhaps safer, especially forpatients who are on anticoagulation medications toreduce the risk of cardiovascular complications.

TOPICAL VS TOPICAL PLUS INTRACAMERAL INJECTION

Topical anesthesia is nothing short of a revolutionfor cataract surgery. According to a survey of French

ophthalmologists, conducted by Richard Gold, 38.1%of respondents said that they used topical alone in2008, which was an increase from the 35.1% and33.21% who used topical alone in 2007 and 2006,respectively (Figure 1 and Table 1). However, there aredisadvantages to using topical anesthesia alone,namely the potential for patients to feel suddendiscomfort intraoperatively with manipulations, suchas when touching the iris, in cases of intraocularpressure (IOP) fluctuations, and when the IOL unfoldsin the eye.

Therefore, some surgeons prefer to use topicalanesthesia in combination with an intracameralinjection of lidocaine, and in 2008, 19.8% of Frenchcataract surgeons who responded to the survey usedthis combination. This was a slight decrease from the

20% and 20.6% whopreferred this combinationin the previous 2 years,respectively. There can,however, be disadvantagesto using intracameralinjections of anesthesia aswell, such as the fact thatthere is no commerciallyavailable solution approvedfor intracameral injection.The associated risks includedilution or wrong dosage,corneal endothelialdamage, or toxic anteriorsegment syndrome, whichmay complicate surgery.

BENEFITS OF VISTHESIAI have found much

benefit in using VISTHESIAFigure 1. Anesthesia procedure rates from 2000 to 2008 in France.

I recommend VISTHESIA to all of myresidents and use it routinely myself.

(Carl Zeiss Meditec). The advantages of this combinedophthalmic viscosurgical device (OVD) and anestheticare to prevent the previous disadvantages associatedwith topical alone or topical plus intracameral.Incorporating the use of VISTHESIA means morecomfort for the patient and more comfort for thesurgeon. I feel relaxed knowing that patients will bepain-free throughout the duration of the procedure.For instance, I can use iris retractors and remainconfident that I am not inducing any pain. At theBordeaux University Medical School, we do not useany systemic sedation because we are very confidentin the efficacy of VISTHESIA.

We incorporated the use of VISTHESIA almost 6years ago and continue to routinely use it in almost allcataract patients. In our experience, patientsappreciate this option because there is no injectionand therefore a less aggressive form of anesthesia.Another nice thing about using VISTHESIA is thatthere was no change to our surgical process, which isdescribed in detail herein.

Before applying VISTHESIA to the ocular surface, weuse betadine to reduce the risk of infection. Thepatient is informed that he may feel a few seconds of atingling sensation during application of theVISTHESIA, but immediately afterward he should bepain-free and comfortable. Next, the anterior chamberis filled with VISTHESIA intracameral so that thecontinuous curvilinear capsulorrhexis can be formedand phacoemulsification initiated. We then inject asecond round of VISTHESIA intracameral before IOLimplantation, to maintain patient comfort throughoutthe unfolding of the IOL.

Great care is taken to remove the remaining OVD

from the anterior chamber and from behind the IOLin the bag, which subsequently avoids anypostoperative increases of IOP as well as any potentialcorneal toxicitiy as seen in some high-risk patientswith Fuch’s endothelial dystrophy.

I remove all OVD after checking the location of theIOL, making sure it is in the bag and centered. Usingthe I/A probe, I first wash the anterior chamber andthen remove the OVD from behind the optic of theIOL inside the capsular bag.

RESIDENT TRAININGVISTHESIA is also an indispensible tool for resident

training. Teaching cataract surgery is not always easyunder topical anesthesia alone, as the procedurestypically take extra time under the care of virginhands. Years ago, residents seemed to be confidentperforming their first cataract surgeries with thepatient under peribulbar anesthesia; however, as thetrend shifted away from its use residents found otheranesthetics with which they grew comfortable with.VISTHESIA is at the top of this list, because they canbe trained with a high degree of safety using moderncataract surgery techniques. I recommend it to all ofmy residents and use it routinely myself. ■

Joseph Colin, MD, is Chairman of theDepartment of Ophthalmology at BordeauxUniversity Medical School, Bordeaux, France.Professor Colin states that he has nofinancial interest in the products orcompanies mentioned. He may be reached at e-mail:[email protected].



We incorporated the use of VISTHESIA almost 6 years ago

and continue to routinely use it inalmost all cataract patients.

TABLE 1. PERCENTAGE OF CATARACT CASESPERFORMED UNDER TOPICAL ANESTHESIA IN FRANCE

2008 (%) 2007 (%) 2006 (%)

Topical alone 38.1 35.1 33.21

Topical + intracameral 19.8 20 20.6

Peribulbar 28.9 30.2 31.6

Sub-Tenon 9.1 11 10.6

VISTHESIA means more comfort forthe patient and more comfort for the

surgeon.

Survey conducted by Richard Gold



This formulation saves time in the operating room.

BY KARIN WALLENTÉN, MD, PHD

Long-Term Experience With VISTHESIA

The importance of ophthalmic viscosurgical devices(OVDs) is indisputable, and the number of surgeonswho rely on its protective benefits are numerous.

When applied intraoperatively, OVDs not only protectintraocular tissue and the various segments of the eye, butthey also create stability during the traumatic manipulationsassociated with ophthalmic procedures. OVDs create andmaintain space in the anterior chamber and capsular bagduring cataract surgery, allowing the surgeon to confidentlyperform phacoemulsification and lens implantation.

Simply put, VISTHESIA (Carl Zeiss Meditec) is my OVD ofchoice. However, this product is more than just an OVD; italso has anesthetic properties. By combining the protectivequalities of an OVD with the pain-relieving qualities oflidocaine, I can assure that patients will be comfortablewhile I am working inside their eye. VISTHESIA has twocomponents, (1) topical to maintain hydration on thecorneal surface and provide topical anesthesia and (2) intracameral to protect the eye during surgery. In mypractice, we prefer to use only the intracameral formulation.

EXCELLENT CHOICEVISTHESIA is not just a good choice for inexperienced

surgeons who may take a little longer to operate orsurgeons who are transitioning to the use of topicalanesthesia, but it is also an excellent choice for surgeonsin high-volume clinics and those who want to offerpatients the optimal chance for a pain-free, positivesurgical experience. After practicing cataract surgery formany years, I have come to find that the benefits of VISTHESIA far surpass the qualities of any other OVD.

I have been using this product since 2004. If I had todecipher the top three benefits of VISTHESIA, in order, theywould be: the time it saves in the operating room, thedecreased risk of contamination (because we don’t have touse an extra syringe for anesthesia), and the level of patientcomfort it provides. Secondary reasons for its use includethe superb optical clarity, which does not inhibit my view ofthe eye during surgery, and the ease of removal withirrigation and aspiration at the end of the procedure.

CASES FOR THE USE OF VISTHESIAAt my clinic, we use VISTHESIA in every single cataract

surgery procedure we perform. It is our standard of care,with all surgeons preferring its use to any other OVD. Withthat said, there are certain cases where the use of VISTHESIAis extremely warranted, such as any case for which surgery isexpected to run long or has the risk for complications. If thenucleus is exceptionally hard and phacoemulsification willtake longer than normal, VISTHESIA will keep the patientpain-free until it is removed from the eye at the end of theprocedure. My cataract surgeries usually last between 7 and10 minutes, but if I know that a particular case will runlonger than this, I tend to use both VISTHESIA and anadditional viscoadaptive OVD. This strategy maintains theocular structure and acts as a supplementary protection forthe endothelium. For example, if the patients’ nucleus isgrade 3 or 4, or if there is a presence of Fuchs’ endothelialdystrophy or zonular weakness, I will use two OVDs.

Some surgeons are concerned that lidocaine may have atoxic effect on the endothelium if left on the eye for morethan 20 minutes. With VISTHESIA, this worry is eliminated.My surgical technique includes one paracentesis followed byapplication of VISTHESIA to the anterior chamber. Afterapplication of the OVD, I create the main temporal clearcorneal incision. I create the capsulorrhexis, performphacoemulsification and irrigation and aspiration, and thenI re-apply VISTHESIA before inserting the IOL into the eye. Iam careful to remove all of the VISTHESIA from thecapsular bag at the end of surgery.

My patients do not complain of pain or even discomfortduring surgery. When combined with the fact thatVISTHESIA saves me time in the operating room andreduces the risk of contamination, I believe this product isthe standard of care for cataract surgery. ■

Karin Wallentén, MD, PhD, is a ConsultantSurgeon in the Department of Ophthalmology,Växjö Hospital, Sweden. Dr. Wallenten states thatshe has no financial interest in the products orcompanies mentioned. She may be reached at e-mail: [email protected].

The benefits of VISTHESIA far surpassthe quality of any other OVDs.

I believe this product is the standard ofcare for cataract surgery.

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