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Biological Activity of Insecticidal Toxins: Structural Basis, Site-Directed Mutagenesis and Perspectives

Alparslan Apan

Anaesthetic Management in Cataract Surgery

J. Esclapez

M. Camacho

C. Pire

M.J. Bonete

Biochemical Analysis of Halophilic Dehydrogenases Altered by Site-Directed Mutagenesis

M. Tang

K.J. Wierenga

K. Lai

Use of Site-Directed Mutagenesis in the Diagnosis, Prognosis and Treatment of Galactosemia

Lawan Abdu

The Management of Age Related Cataract in Sub-Saharan Africa

Kemal Örnek

Cataract Surgery in Retina Patients

Rosario Díez

Lourdes Jordano

César Hita

Toxic Anterior Segment Syndrome (TASS) and Prophylaxis Against Postoperative Endophthalmitis

Atilla Bayer

Combined Cataract and Glaucoma Surgery

Takao Tanaka

Maiko Hirose

Shigemitu Ishii

Satoshi Fujita

Keisuke Kimura

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10 
Dual OVD (Ophthalmic Viscosurgical Devices) 
Sealing Technique 
Takao Tanaka1,*, Maiko Hirose1, Shigemitu Ishii1,  
Satoshi Fujita1 and Keisuke Kimura2 
1Hachioji Medical Center, Tokyo Medical University Hospital, Hachioji Tokyo 
2Department of Ophthalmology, Tokyo Medical University, Tokyo, 
Japan 
1. Introduction 
The soft shell technique (Arshinoff SA) is an excellent technique for protecting the corneal 
endothelium, particularly when performing microincision cataract surgery (MICS) 
(Tsuneoka H, et al.; Osher RH; and Agarwal A, et al.). We have observed that this technique 
is often associated with an increase in intraocular pressure (IOP) after surgery (Figure 1). 
Here we conducted a preliminary retrospective study to evaluate increases in IOP after 
surgery using the soft shell technique with different incision sizes. The incidence of an IOP 
of at least 22 mmHg at 1 day after surgery is increased when a narrow incision size is made 
during surgery. Therefore, the IOP spike may depend on the incision size. 
 
 
Fig. 1. IOP Values after Surgery Using the Soft Shell Technique  
                                                                 
* Corresponding Author 
 
Cataract Surgery 138 
This was a preliminary retrospective study (n=75 cases). For cataract surgery, the soft shell 
technique is excellent for protecting the corneal endothelium. In our experience, however, 
the use of this technique during minimal incision cataract surgery (MICS) is often associated 
with an increase in postoperative intraocular pressure, especially 1 day after surgery in cases 
in which a 2.2-mm clear corneal incision was made.  
Based on this impression, we designed a dual Ophthalmic Viscosurgical Device (OVD) 
sealing technique, anticipating that use of this sealing technique in combination with MICS 
would attenuate the IOP elevation and better protect the cornea as by contributing to 
maintain the appropriate anterior chamber depth during surgery. 
The technique involves filling the anterior chamber with a low-molecular-weight 
ophthalmic viscosurgical device (LMW-OVD), using sodium hyaluronate (SH; Opegan®, 
Santen) for corneal protection (Nagahara M & Shimizu K). In addition, another OVD with a 
different surface tension, preferably one containing SH and chondroitin sulfate (SH/CS; 
Viscoat®, Alcon) is used to seal the wound to prevent marked leakage of the LMW-OVD 
from the anterior chamber. The purpose of this study was to evaluate the effect of this dual 
OVD sealing technique, combined with MICS, on the postoperative IOP and corneal 
protection. 
2. Methods 
Technique: After the initial paracentesis, a cannula was inserted into the anterior chamber 
and the LMW-OVD was injected. After filling 70% of the anterior chamber, the secondary 
SH/CH-OVD was injected around the wound. Injection of the LMW-OVD was resumed, 
penetrating the SH/CS-OVD mass and sealing the wound (Figure 2). 
 
 
 
 
 
 
Fig. 2. The dual-OVD sealing technique 
The anterior chamber is filled with LMW-OVD. The inside wound is sealed using a 
secondary OVD SH/CS-OVD with a different surface tension. 
 
Dual OVD (Ophthalmic Viscosurgical Devices) Sealing Technique 139 
3. Clinical evaluation 
The retrospective study involved a total of 165 eyes that underwent MICS by the same 
surgeon (T.T.). Subjects that underwent MICS with a 2.2-mm clear corneal incision and 
micro co-axial phaco were classified into five groups as follows: Group 1 (n=29), the soft 
shell technique (SH/CS-OVD and HMW-OVD, Healon ®, AMO); Group 2 (n= 29): a high 
molecular weight OVD (HMW-OVD1: Healon ®) was used; Group 3 (n=33) HMW-OVD2 
(Opegan Hi ®, Santen); Group 4 (n=40): dual-OVD sealing technique (DOS) using a LMW-
OVD and SH/CS-OVD; and Group 5 (n=34): LMW-OVD alone. Intraocular pressure and 
percent corneal endothelial cell loss were measured before surgery, and at 1, 3, and 5 days 
after surgery.  
4. Results 
At day 1 after surgery, IOP was increased in all cases (Figures 3 and 4) and did not 
significantly differ between groups. After day 1, however, IOP was significantly higher in 
Group 1, in which the soft shell technique was used, compared to Groups 2-5.  
 
 
  
 
 
Fig. 3. Intraocular pressure 
These findings suggest that the soft shell technique tends to induce an increase in the IOP 
compared with the non-soft shell techniques. The OVD used did not significantly affect 
corneal endothelial loss rate; mean cell area and the coefficient of variation did not differ 
significantly between groups (Figures 5,6, and 7). 
 
Cataract Surgery 140 
 
Fig. 4. Differences in the IOP elevation values 
 
 
 
 
 
Fig. 5. Mean corneal endothelial cell loss rate  
 
Dual OVD (Ophthalmic Viscosurgical Devices) Sealing Technique 141 
 
 
 
 
Fig. 6. Difference in mean cell area between before and after surgery  
 
 
 
 
Fig. 7. Coefficient of variation  
 
Cataract Surgery 142 
5. Discussion 
Sodium hyaluronate demonstrates remarkable viscoadaptability and prolonged retention at 
the lower flow rate is associated with a high residual volume (Tanaka T, et al.). Leakage of 
the LMW-OVD is prevented when using the dual OVD sealing technique because the 
injection of a secondary OVD with a different surface tension facilitates maintenance of the 
anterior chamber depth. 
Although the soft shell technique (Arshinoff SA) is useful for protecting the cornea, it is 
sometimes associated with an increased postoperative IOP when MICS is performed with a 
small incision. Thus, the IOP elevation may be due to residual OVD. Longer wash periods 
are therefore required to wash out the residual OVD or, when performing MICS, the 
irrigation volume must be very low. In such cases, the use of a LMW-OVD is expected to 
prevent the IOP elevation. 
In our dual sealing procedure, a lower volume of the OVD is used than in the soft shell 
technique, allowing for the use of a LMW-OVD instead of a high molecular of OVD as the 
main filling in the anterior chamber. The SH/CS-OVD may prevent leakage and help to 
maintain an adequate anterior chamber depth. Thus, the dual OVD sealing technique 
appears to be more appropriate for small incision surgery. 
The advantages of the dual sealing technique include: 1. Corneal protection by the LMW-
OVD and 2. Low residual OVD, which helps prevent the elevation in IOP.  
6. Financial disclosure  
Takao Tanaka received partial support in the form of grants from Santen Pharmaceutical 
Company, Ltd., Osaka, Japan. 
7. References 
Agarwal A, Agarwal A, Agarwal S, Narang P, Narang S. Phaconit: phacoemulsification 
through a 0.9 mm corneal incision. J Cataract Refract Surg 2001; 27:1548–1552 
Arshinoff SA. Soft Shell technique, Dispersive-cohesive viscoelastic soft shell technique J 
Cataract Refract Surg 1999; 25:167-173  
Nagahara M, Shimizu K. Protecting the corneal endothelium with viscoelastic material 
during phacoemulsification. Rinsho Ganka (Written in Japanese) 1994; 48:900-901 
Osher RH. Micro coaxial phacoemulsification. Part 2: clinical study. J Cataract Refract Surg 
2007; 33:408–412 
Tsuneoka H, Shiba T, Takahashi Y. Ultrasonic phacoemulsification using a 1.4 mm incision: 
clinical results. J Cataract Refract Surg 2002; 28:81–86 
Tanaka T, Kimura K, Usui M. Adhesive retention of sodium hyaluronate ophthalmic 
viscosurgical devices in an acrylic tube model and in porcine-eye corneal 
endothelium with different irrigation rates. J Cataract Refract Surg 2009；35: 
2008-2013 


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Biological Activity of Insecticidal Toxins: Structural Basis, Site-Directed Mutagenesis and Perspectives

Anaesthetic Management in Cataract Surgery

Biochemical Analysis of Halophilic Dehydrogenases Altered by Site-Directed Mutagenesis

Use of Site-Directed Mutagenesis in the Diagnosis, Prognosis and Treatment of Galactosemia

The Management of Age Related Cataract in Sub-Saharan Africa

Cataract Surgery in Retina Patients

Toxic Anterior Segment Syndrome (TASS) and Prophylaxis Against Postoperative Endophthalmitis

Combined Cataract and Glaucoma Surgery

Dual OVD (Ophthalmic Viscosurgical Devices) Sealing Technique

Intracameral Mydriatics in Cataract Surgery

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