1. Healon5 Visco-sandwich Technique for Phacoemulsification in Morgagnian Cataract Surgery Masaki Sato, MD Tetsuro Oshika, MD Department of Ophthalmology University of Tsukuba Japan The authors have no commercial or proprietary interest in any of the companies, products, or methods described in this presentation.

2. A morgagnian cataract is a hypermature lens in which the total liquefaction of the cortex and the dense nucleus sinks inferiorly. Aside from the total reduction of vision, serious sequelae such as phacolysis may result. Phacoemulsification for morgagnian cataract, which many ophthalmic surgeons would hesitate to perform, demands high- degree skill and considerable experience from the operator. The fluctuating anterior capsule complicates creating a CCC. Additionally, the complete outflow of the liquefied cortex at the very beginning of creating a CCC can result in high rates of the posterior capsule rupture during PEA. We expected that a technique which wrapped the morgagnian hard nucleus in the “visco-shell” made of Healon ® 5 (AMO, Inc.) brought high ability to maintain both intracameral and intracapsular stability during PEA (Figure 1). Introduction

3. BA CD Figure 1. The outline of Healon5 visco-shell (visco-sandwich) technique. A) Healon5 injection into the anterior chamber. B) Additional Healon5 injection between the nucleus and the posterior capsule. C) In the visco-shell made of Healon5, PEA under lowered fluidics is meticulously performed. D) Theoretically, the visco-shell is expected to retain its original form at the copletion of PEA.

4. To investigate the efficacy of Healon5 visco-shell (visco-sandwich) technique for phacoemulsification in morgagnian cataract surgery. Purpose

5. Subjects 3 eyes of three patients with typical morgagnian cataract had PEA and IOL implantation from December 2006 through June 2007.

6. The USST using Healon5 and typan blue 0.1% CCC No hydrodissection Healon5 visco-shell (visco-sandwich) technique Healon5 injection between the lens nucleus and the posterior capsule to lift the entire nucleus and expand the capsular bag. The nucleus is slightly subluxated out of the bag. Phaco-chop technique in the middle of the visco-shell Parameters during phacoemulsification vacuum 180 mm Hg, AFR 20 cc/min, phaco power 70%, ultrasound pulse rate 10 pulses/sec, and bottle height 80 cm. No suction of cortex Healon5 intracapsular re-injection IOL intracapsular fixation The 2-compartment technique (500 mm Hg vacuum, 28 cc/min AFR) Surgical Technique

7. ab c def gh i   b) At supine position, the lens nucleus sinks into the liquefied cortex. c) Outflow of the liquefied cortex at the very beginning of a capsulorhexis (Arrows). d) Note that the intracapsular color changes from white to brown in an instant. Asterisks  Spilled cortex. e) Healon5 visco-shell (visco-sandwich) technique. f) The slightly subluxated nucleus. g) PEA in the middle of the visco-shell. The intracameral stability is extremely good. h) An IOL intracapsular fixation as usual. i) No any postoperative complications POD 1. Figure 2. Preoperative (a), intraoperative (b-h), and postoperative (i) anterior segment photographs of a typical morgagnian cataract patient.

8. Complete CCC, safe PEA, and IOL intracapsular fixation No any intraoperative complications Neither corneal edema nor Descemet´s fold on POD 1 No postoperative IOP-lowering medication The endothelial cell loss rate POM 3 of under 10 %. No any postoperative complications Results (In all eyes)

9. Healon5 sandwich technique in vitrectomized eyes (Sudan et al.) Injection under the second piece after half the nucleus is emulsified. Healon5 visco-shell (visco-sandwich) technique in morgagnian cataract eyes (Current study) Injection under the whole nucleus prior to PEA. Wrapping the whole nucleus in the “visco-shell” made of Healon5. A : Nuclear size : Morgagnian cataract << Post-vitrectomized cataract In case of a usual vitrectomized eye, it is not appropriate that Healon5 would be injected under the whole nucleus prior to PEA, because acute IOP elevation might cause complications such as posterior capsule dehiscence followed by nucleus drop into the vitreous cavity. In case of an eye with a large CCC and complete hydrodelineation, however, Healon5 might be injected at the early stage of PEA even if a vitrectomized eye. Discussion 1 ( Visco-shell or Sandwich) Q : Difference in stage of Healon5 jnjection

10. Discussion 2 ( How to use Healon5 ) The visco-extraction technique is good enough for such a case ! But, in case of typical morgagnian cataract as shown in Figure 2, what do you do ? Using visco-shell (visco-sandwich) technique with a viscoadaptive OVD such as Healon5, it is considered that phacoemulsification with the appropriate setting of parameters can be performed safely irrespective of the surgeon's experience. Figure 3. Atypical morgagnian cataract with spontaneous posterior capsular rupture (only a few cases reported). j) A dislocated embryonic nucleus oscillates simultaneously with eye movement. k) Posterior capsule adhered severely to anterior capsule. l) Nucleus floating in the Berger's space. m) Nucleus removal with so- called the visco-extraction technique. lm jk Typical or Atypical

11. DisCoVisc ® (hyaluronic acid 1.65%-chondroitin sulfate 4%, Alcon Laboratories, Inc.) : a viscous dispersive OVD Retention : DisCoVisc >> Healon5 Removal : DisCoVisc >> Healon5 Closest to the ideal OVD, in that it remains in the eye when necessary and is easy to remove at the end of surgery. DisCoVisc may be able to be used instead of Healon5 in performing visco-shell (visco-sandwich) technique. Discussion 3 ( Another OVD)

12. Healon5 visco-shell (visco-sandwich) technique has high ability to maintain both intracameral and intracapsular stability during phacoemulsification under lowered fluidics in morgagnian cataract surgery. This technique may be also applied to cases in which the rock-hard nuclear fragments would remain with no cortex in usual cataract surgery. Our results encourage further investigations of the effect of this technique on maintenance of intraocular stability during phacoemulsification in various cases. Conclusions