Put your eye on the grindstone
Reviewed by Andreas F. Borkenstein, MD
According to Andreas F. Borkenstein, MD, who is in private practice in Graz, Austria.
Borkenstein presented the data at the 2022 American Society of Cataract and Refractive Surgery Annual Meeting in Washington, DC. The study’s co-author is Boris Malyugin, MD, PhD, professor of ophthalmology and deputy director general of the S. Fyodorov Federal State Institute of Ocular Microsurgery in Moscow.
Borkenstein noted that the step of removing cortical remnants and primary capsular fibrosis is critical in cataract surgery because damage to the posterior capsule can occur. 2 years ago, the technique was born out of his recognition of the “excellent” ability of a highly viscous cohesive ophthalmic viscosurgical device (DVO) (Pe-Ha-Luron F 2.2%; Albomed Germany) to eliminate fibrosis capsular without damaging the posterior capsule with the irrigation/aspiration cannula during the mechanical capsular polishing step.
With a normal jet during the procedure, residues often remain or the capsule can be destroyed by the pressure of the jet. Over the next year, Borkenstein searched for an ophthalmologist with a surgical and scientific background. This led him to Malyugin, an internationally recognized expert in difficult cases of cataract surgery and inventor of useful instruments.
Borkenstein explained that the idea of using a stream of fluid from the irrigation cannula attached to the balanced salt solution (BSS) syringe to clean the capsule dates back to the late 1990s (Steven Arshinoff, MD, and Thomas Neuhann, MD) and the safety and efficacy of the procedure have been reported.1.2
The difference between the proven procedure and the one being discussed is that the latter does not use a BSS stream but rather a bolus from the OVD. This approach attempts to avoid excessive collateral trauma from irrigating the delicate corneal endothelium and posterior capsule.
Cohesive OVDs seem ideal for this technique as they have high molecular weight and surface tension and consist of large molecules. In addition, they are ideal for maintaining the anterior chamber, helping to achieve capsulorrhexis and creating space. They are easy to remove due to their high surface tension, Borkenstein explained.
Borkenstein described the process in 3 steps. First, the capsular bag is filled to approximately one-third capacity with the cohesive, highly viscous OVD to create the bolus.
Second, the surgeon augments the BSS stream by introducing a 27 or 30 gauge cannula attached to the syringe and directing it to the posterior capsule slightly tangential to the OVD bolus. Finally, the OVD bolus begins to spin and creates a sort of “millstone”.
Borkenstein explained that this can be detected when the thick viscoelastic cords begin to spin rapidly within the capsule in the form of a ball with a relatively rough surface that grinds down the cortical material. The jet stream remains in the same position (i.e. tangential to the posterior capsule).
Air bubbles in the anterior chamber remain in the same location, indicating that no fluid or shear force is reaching the anterior chamber or endothelium/cornea.3
The first cases of VOD
Borkenstein pointed out that the first 62 cases were carried out without problems. No intraoperative or postoperative complications were detected; on day 1 after surgery, no corneal edema or hypertension occurred. Mean best-corrected visual acuity was –0.01 ± 0.11 logarithm of minimum angle of resolution.
The procedure appears safe, with no additional irrigation trauma and no pressure, mechanical force, or sharp objects applied to the capsule. “The anterior chamber and corneal endothelium are also safe because the OVD stays in the capsule due to its molecular weight,” he said.
The new technique added only 30 to 60 seconds to the time of routine cataract surgery.4 A big advantage in difficult cases is that it can potentially reduce the risk of posterior capsular opacification (PCO) developing after the operation. No additional surgical device was required. It’s safe and simple, ideal for difficult cases like post-traumatic eyes, pseudo-exfoliation syndrome or soft iris syndrome, he noted.
Additionally, Borkenstein explained that it will be interesting to see in the long term if the rate of PCO is reduced with this technique, and with more surgeons performing the technique worldwide, if the rate of intraoperative complications can be reduced.
Another multicenter study is planned to evaluate long-term results regarding PCO level and endothelial cell count with more patients. Additionally, Borkenstein would like to demonstrate the milling effect in a laboratory study using the “Miyake-Apple posterior video analysis technique” and is seeking further collaboration.
Andreas F. Borkenstein, MD
This article is adapted from Borkenstein’s presentation at the annual meeting of the American Society of Cataract and Refractive Surgery, held in Washington DC. He has no financial interest in any aspect of this report.
1 Liu Z, Cao Q, Qu B, et al. Fluid jet technique to polish the posterior capsule for phacoemulsification surgeries: evaluation of efficacy and safety. J Refractory cataract surgery. 2020;46(11):1508-1514. doi:10.1097/j.jcrs.0000000000000319
2 Arshinoff SA, Neuhann T. Commentary on: fluid jet technique to polish the posterior capsule for phacoemulsification surgeries: evaluation of efficacy and safety. J Refractory cataract surgery. 2021;47(8):1103. doi:10.1097/j.jcrs.0000000000000714
3 Borkenstein AF, Borkenstein EM, Malyugin B. Removal of residual cortical material during cataract surgery: visco polishing and grinding wheel effect as a new surgical technique. Eur J Ophthalmol. 2021;32(3):1817-1820. doi:10.1177/11206721211059909