LETTERS

REPLY: We agree with the authors that while thereare techniques to minimize any wound-burn riskwithHealon5, ultrasound in an anterior chamber filledwith this OVD can be very unforgiving and should

Healon5 and corneal wound burnduring phacoemulsification

In the article by Floyd et al.1 concerning the effect ofincisional friction and ophthalmic viscosurgical de-vices (OVDs) on heat generation during phacoemulsi-fication, sodium hyaluronate 2.3% (Healon5) andsodium hyaluronate 3.0%–chondroitin sulfate 4.0%(Viscoat) were associated with a greater increase incorneal temperature than the other OVDs. This was at-tributed to the obstruction of fluid circulation throughthe phaco tip as well as to the ability of these OVDs topromote exothermic reactions. We would like to de-scribe 2 cases of corneal wound burn after phacoemul-sification related to nonoptimal use of Healon5.

The first case was a 66-year-old woman who hada grade II nuclear cataract (Lens Opacities Classifica-tion System III [LOCS]2) in the left eye with a 4.0 mmpupil. The logMAR visual acuity was 0.6 (pinhole0.3). The second case was a 71-year-old who also hada grade II nuclear cataract (LOCS III) and a logMARacuity of 0.5 (no improvement with pinhole) in theright eye with the same size pupil. There was no evi-dence of other ocular pathology in either case. Both pa-tients had had uneventful phacoemulsification in thefellow eye by the same surgeon (H.S.) using iris hooks,sodium hyaluronate 1.4% (Healon GV), and theBausch & Lomb Millennium machine with routinemachine parameters (sculpting: maximum ultrasound80%, 120 pulses per second, 50% duty cycle, vacuum50mmHg, and bottle height 80 cm; quadrant removal:maximum ultrasound 50%, 80 pulses per second, 50%duty cycle, vacuum 120 mm Hg, and bottle height105 cm) on the venturi pump mode with final uncor-rected postoperative logMAR visual acuities of 0.0.

Phacoemulsification in the second eye was per-formed by the same surgeon (H.S.) using the sametechnique, instrumentation, machine, and parametersexcept that iris hooks were not used and Healon5was used instead of Healon GV. The standard 2.5 mmincision was not considered to be tight for a Micro-Flow tip. In both eyes, Healon5 was used as the soleOVD and filled the anterior chamber completely. Thechoice was based primarily on the ability of Healon5to dilate the pupil as well as provide corneal endothe-lial protection.

Both patients subsequently developed a cornealwound burn during phacoemulsification of the nu-cleus. In the first patient, the burn required 3 interrup-ted 10-0 nylon sutures and in the second, 4 interrupted10-0 nylon sutures; there was no evidence of woundleakage at the end of the procedure in either case. Post-operatively, with-the-wound astigmatism was notedin both eyes, with a refraction of C0.25 �1.5 � 95 inthe first patient and C2.5 �1.0 � 45 in the second.

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Healon5 is a viscoadaptive OVD that combines co-hesive with dispersive properties and therefore canbe used as a routine OVD during cataract surgery.3

Moreover, it is a useful tool in managing cases withsmall pupils intraoperatively. The highly concentratedlong-chained molecules of Healon5 are able to movethe iris effectively and dilate the pupil more than anyother OVD at zero shear.4

As suggested by Floyd et al.,1 creating a fluid spacearound the phaco tip before phacoemulsificationshould circumvent the problem of an OVD-relatedwound burn. This can be performed by partially fillingthe anterior chamber with the OVD and injecting bal-anced salt solution (BSS) underneath, as described byArshinoff in the ultimate soft-shell technique.4 Fur-thermore, the risk for developing a phaco burn couldbe further minimized with this technique if phaco-emulsification were limited to the capsular confinesand the BSS space, as this would limit the amount ofHealon5 coming to the phaco tip.5 Another way is toremove some OVD with the ultrasound tip usinga high vacuum setting before phacoemulsification isstarted.6 Although this is easier to perform than thefirst method, it markedly decreases the amount ofOVD in the anterior chamber and effectively dimin-ishes the advantages offered by its presence; ie, pro-tecting the corneal endothelium and enhancingintraoperative mechanical dilation of the pupil.

Ahmed Sallam, MRCOphthShahram Kashani, MRCOphthHooman Sherafat, FRCOphth

London, United Kingdom

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friction and ophthalmic viscosurgical devices on the heat genera-

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2. Chylack LT Jr, Wolfe JK, Singer DM, et al. The Lens Opacities

Classification System III; the Longitudinal Study of Cataract

Study Group. Arch Ophthalmol 1993; 111:831–836

3. Arshinoff SA, Jafari M. New classification of ophthalmic viscosurgi-

cal devicesd2005. J Cataract Refract Surg 2005; 31:2167–2171

4. Arshinoff SA. Using BSS with viscoadaptives in the ultimate soft-

shell technique. J Cataract Refract Surg 2002; 28:1509–1514

5. Arshinoff SA. Modified SST-USST for tamsulosin-associated

intraocular floppy-iris syndrome. J Cataract Refract Surg 2006;

32:559–561

6. Osher RH, Marques FF, Marques DMV, Osher JM. Slow-motion

phacoemulsification technique. Tech Ophthalmol 2003; 1:73–79

0886-3350/07/$dsee front matter

doi:10.1016/j.jcrs.2006.11.026