VISCOELASTIC MATERIALS IN

OPHTHALMOLOGY

DR OLORUNDARE O.K.
25/05/2011

OUTLINE
Introduction
Rheologic

characteristics
Desired Properties of an Ideal VEM
Classification of VEM
Viscoelastic components of VEM
Commercial VEM preparations
Uses of VEM
Complications
Conclusion

INTRODUCTION
A

group of agents with varying degrees of

viscosity and elasticity used during
ophthalmic surgery.

Dual

Properties

Viscosity of a fluid
Elasticity of a gel or solid
Viscosurgery

Use of substances with viscous, elastic and

INTRODUCTION
Concept

for development

precision tissue specific action

Also

referred to as OVDs

Ophthalmic Viscosurgical Device

RHEOLOGIC CHARACTERISTICS
Relevant

rheologic characteristics of

OVDs

Viscosity
Elasticity
Surface tension
Pseudoplasticity

RHEOLOGIC CHARACTERISTICS
Viscosity
Is the measure of resistance to flow, (a function
of the molecular weight of the substance.)
Also dependent on the rate of flow, which is
also known as the shear rate, varies inversely
with temperature.
The viscosity of a solution can be increased by
increasing either the concentration or the
molecular weight of the solution.

RHEOLOGIC CHARACTERISTICS
Elasticity

the ability of a solution to return to its

original shape after being stressed.
The amount of elasticity increases with
increasing M.W. and greater chain
length of the molecules

RHEOLOGIC CHARACTERISTICS
Pseudoplasticity

ability to transform when under

pressure, from a gel-like substance to
a more liquid substance.
The more pseudoplastic a material is,
the more rapidly it changes from being
highly viscous at rest to a thin, watery
solution at high shear rates.

RHEOLOGIC CHARACTERISTICS
Surface

Tension

Determines the coating ability of the

VEM
can be estimated by measuring the angle
formed by a drop of the VEM on a flat
surface
Lower surface tension and lower contact
angle indicate a better ability to coat .

Desired Properties of an Ideal

VEM
Sterile
Non

inflammatory
Electrolyte balanced
Water soluble
Non toxic
Non immunogenic
PH buffered
Highly purified
Non pyrogenic
Optically clear
Coats tissues and
instruments

Easy

to instill
Easy to remove
Inert
Long shelf life
Particle free
Does not obstruct aqueous
outflow
Retention under positive
pressure in the eye
Does not interfere with
instruments or IOL
placement

Classification of VEMs
According

to

Zero shear viscosity, directly

proportional to the m.w.
Cohesive strength
Viscocohesive VEMs
Viscodispersive VEMs
Viscoadaptive VEMs

Classification of VEMs
Cohesive VEMs
have high viscosity, high molecular
weight, high pseudoplasticity, and
high surface tension.
are better for manipulation of
tissue and space maintenance
are easily removed
have poor coating ability

Classification of VEMs
Viscodispersive

VEMs
have lower viscosity, lower
molecular weight, lower surface
tension, and lower pseudoplasticity
are better for coating surfaces
have poor space maintenance
ability
are not easy to remove

Classification of VEMs
Viscodispersive

VEMs

Have both cohesive and dispersive

properties depending on the degree
of turbulence present
At low shear rates, are extremely
viscous and cohesive, but at
midrange flow rates they fracture,
manifesting dispersive behavior

Viscoelastic components of
VEMs
Sodium

Hyaluronate:
high molecular weight biopolymer occurring
in many connective tissues throughout the
body
Manufactured from rooster combs, bovine
vitreous, umbilical cord
Most elastic, viscous,& pseudoplastic
T1/2 1 day in aqueous, 3 days in vitreous
Disadvantages- High cost, requires
refrigeration, not autoclavable, poor coating
ability

Viscoelastic components of
VEMs
Chondroitin

Sulfate:
medium molecular weight biopolymer,
mainly found in extracellular matrix of
connective tissue e.g cornea
Manufactured from Shark fin cartilage
Has good coating ability, little/ no IOP
elevation post operatively
Poor space maintenance

Viscoelastic components of
VEMs
Hydroxypropyl

Methylcellulose (HPMC):
cellulose polymer composed of D-glucose
molecules linked together by -glycosidic
bonds, occurs in plants not animals
Made from cotton and wood pulp
Low cost, autoclavable, Easy storage at
room temperature, good coating ability
Not metabolized intraocularly, easily
irrigated
Poor space maintenance

Viscoelastic components of
VEMs
Polyacrylamide

Synthetically produced polymer similar to

hyaluronate
It is a linear long chain molecule,
non toxic, requires no refrigeration and is
inert inside the eye
Rapidly cleared from the AC and because of
its stability does not degrade

COMMERCIAL VEM
PREPARATIONS

Healon, Healon
GV, Healon 5
Amvisc, Amvisc
Plus
AMOVitrax
ProVisc
Viscoat
Ocucoat
Cellugel

Hymecel
Adatocel
Visilon
Ocuvis
MicroVisc
Ophthalin,

Ophthalin Plus

USES OF VEMs
Cataract

Surgery

Protection of corneal endothelium

Control of capillary oozing
In maintenance of AC
In capsulorrhexis
In viscoexpression of lens nucleus CCC
In capsular bag filling and IOL implantation
Protect tissues from vibration & turbulence
Seal small PC rent

USES OF VEMs
Glaucoma

Surgery

In Viscocanalostomy
Keratoplasty

Protect corneal endothelium when

removing corneal button in donor eye
Provides an even and circular trephination
Viscodelamination of cornea in lamellar
keratoplasty

USES OF VEMs
Retinal

detachment Surgery

As vitreous substitutes (help in pushing

retina towards the choroid)
In dissection of epiretinal membrane
(releasing tractional bands)
Achieving hemostasis
Repositioning detached retina

USES OF VEMs
In

Traumatic cases

To separate salvageable tissue from

damaged tissues
To restore collapsed globe in posterior
segment trauma
Miscellaneous

In refractory dry eye syndrome

Viscoanaesthesia

COMPLICATIONS
Iris

prolapse if injected in retroirideal area

Blockage of orifices preventing rapid
wound closure
Hampered movement of drugs
IOP elevation post operatively 6 24hrs
post-op resolves in 72hr
Crystallization on lens surface
Pseudoanterior uveitis
Calcific band keratopathy as occurred as a
complication to Chondroitin sulphate.

CONCLUSION
No

single VEM is ideal under all circumstances

The

Choice of a viscoelastic substance depends

largely on the intended surgical use.

The

physicochemical ppties, desirable & undesirable

clinical effects must be considered when choosing.

Ophthalmologic

surgeons should keep up with recent

developments of OVDs and relevant surgical
techniques for better patient care.

SUTURE MATERIALS IN
OPHTHALMOLOGY

OUTLINE
DEFINITION
CRITERIA

FOR AN IDEAL

SUTURE
CLASSIFICATION OF SUTURES
SUTURE NEEDLES
CONCLUSION

Definition
Suture

is a strand of material that is

used to
approximate and maintain separated
tissue until the natural healing
process occurs or
ligate blood vessels to secure
haemostasis

Criteria for an ideal suture

easy to handle and knot
minimal tissue reaction
does not support bacterial growth
high tensile strength
no allergic reaction
no carcinogenic action
absorbed after serving its function
easy sterilization
inexpensive

CLASSIFICATION OF SUTURES
Sutures

are classified according to

their degradation properties

ABSORBABLE
undergo rapid degradation in tissues,
losing their tensile strength within 60 days.

NON ABSORBABLE
that generally maintain their
strength for longer than 60 days

tensile

CLASSIFICATION OF SUTURES

ABSORBABLE

Natural absorbable sutures are digested by

body enzymes which attack and break
down the suture strand
Synthetic
hydrolyzed

absorbable

sutures

are

hydrolyzation results in a lesser degree of

tissue reaction following implantation.

CLASSIFICATION OF SUTURES

NON ABSORBABLE

not digested by body enzymes or hydrolyzed in body

tissue.
Made from a variety of non biodegradable materials
encapsulated or walled off by the bodys fibroblasts.
Remain where they are buried within the tissues.
When used for skin closure, they must be removed
postoperatively.

ABSORBABLE NATURAL SUTURES

CATGUT

Serosal layer of intestine of cattle or submucosa of

sheep.
Tanned with chromic salt to delay absorption - brown
gamma radiation or ethylene oxide
proteolytic enzymatic digestion.
Plain catgut retains its tensile strength for about a week.
absorption rate is about 10-15 days.
Chromic 17-21days , 30days.
handling of the material is excellent, doesnt snag,
Laying of knots is accurate .Marked tissue reaction

USES

Conjunctival closure

ABSORBABLE NATURAL SUTURES

COLLAGEN SUTURES

From Achilles tendons of cattle.

more consistent in smoothness and strength
than catgut,
Easy to tie,
Less tissue reaction than catgut
Loses strength like catgut

USES

Conjunctival closure

ABSORBABLE SYNTHETIC SUTURES

POLY GLACTIN 910 (VICRYL)
copolymer of glycolic and lactic acid in the ratio 90/10.
Coated-vicryl is a multifilament polyglactin 910 coated
with polyglactin 370 and calcium stearate
Makes the surface smoother and reduces tissue drag,
improves knotting and handling characteristic.
High tensile strength, Secure knotting, Soft and
pliable, Easy to handle, mild tissue reaction. Retains
tensile strength for 2-3wks and total absorption in 6090days.

ABSORBABLE SYNTHETIC SUTURES

POLY

GLACTIN 910 (VICRYL)

Monocryl

(Polyglecapone 25) which is

monofilament vicryl is absorbed in 20 days.

USES
strabismus surgery (6/0)
Oculoplastic surgery (6/0)
Trabeculectomy (8/0)
Conjunctival closure (8/0)
Sclerotomy closure (7/0)

ABSORBABLE SYNTHETIC SUTURES

POLYGLYCOLIC

ACID (PGA) SUTURES (DEXON)

A synthetic absorbable suture produced by the

polymerization of glycolide to polyglycolic acid.
Dexon S - braided PGA without coating
Dexon plus treated with surface lubricant Poloxamer
188
Absorption is by hydrolysis .Total absorption occur at 6090 days post op.
Minimal tissue reaction (no protein),to knot securely
requires 3 throws.

ABSORBABLE SYNTHETIC SUTURES

Has

high tensile strength

Knot slippage is rare
chronic suture infections.
Tissue drag
Sterilization with Ethylene oxide
uses
strabismus

surgery
Eyelid surgeries (6/0)

NON-ABSORBABLE NATURAL SUTURES

BRAIDED

SILK/MERSILK
raw silk thread spun by larva of the silk worm
It behaves as a very slow absorbable suture.
Knots well
dyed black for easy visibility in tissues
Sterilization is by gamma radiation.

USES

Superior rectus bridle during cataract surgery

Traction sutures/eyelid retraction
Temporary traction purposes on Extraocular
muscles (8/0)

NON-ABSORBABLE NATURAL SUTURES

TWISTED

VIRGIN SILK (ETHICON)

Excellent handling property, Knot security

and knots well.
Moderate tissue reaction, tensile strength
lasts 3-6mths, inelastic, suture ends are soft
and well tolerated.

USES

For limbal wound closure as in cataract

surgery (8/0)
Trabeculectomy (9-0 or 8-0)
Conjunctival closure
Skin incisions (7/0)

NON-ABSORBABLE NATURAL SUTURES

COTTON
Natural origin, manufactured by twisting the
seed hairs of long fibre cotton.
Properties are similar to that of silk though
ranked as a weak suture, gains strength
when wet.

NON-ABSORBABLE SYNTHETIC SUTURES

POLYAMIDES/NYLON

(ETHILON)

Nylons are polyamide polymer derived by

chemical synthesis.
monofilament and multifilament forms
Multifilament nylon (Nurolon) More tissue
reaction, Good knot security, black.
Absorption: Its degraded and absorbed in
about 2 years.
Characteristic:- (monofilament)

NON-ABSORBABLE SYNTHETIC SUTURES

POLYAMIDES/NYLON

(ETHILON)
Poor knot security due to a low coefficient of friction,
stiff suture ends which must be buried to avoid
irritation.
Sterilization of nylon sutures is by gamma
irradiation.

USES

Corneal wound closure (suture of choice in cataract

surgery)
Corneal grafting
Oculoplastic surgery

NON-ABSORBABLE SYNTHETIC SUTURES

POLYESTER

(DACRON)
Are polymer of terephthalic acid and glycolethylene.
Have superior strength and durability.

Very little inflammatory reaction,

Elastic and unaffected by tissue fluids. Colour in

Blue or undyed

USES
Cataract surgery
corneal grafting
intraocular suturing
Retinal surgery

NON-ABSORBABLE SYNTHETIC SUTURES

POLYPROPYLENE (PROLENE)

Provide smooth passage through tissue

with minimal tissue reaction,

Very high tensile strength

Inert suture and infected wound could heal
in its presence,
Handles comfortably. Soft and pliable,
The elastic nature of the material locks knot
security

NON-ABSORBABLE SYNTHETIC SUTURES

POLYPROPYLENE (PROLENE)
Colour code: Blue or clear
Sterilization: - By ethylene oxide/autoclaving

USES
Cataract surgery
Corneal grafting
Iris repair
Intraocular lens fixation
Oculoplastic surgery

NON-ABSORBABLE SYNTHETIC SUTURES

METALLIC SUTURES:
Its an alloy of steel with molybdenum, chromium
and nickel.
usually monofilament,
They are used with sophisticated applicators and
stapling guns.

Characteristics: Monofilament steel is extremely strong, Inert,

high knot security
Limitation:-

Metal fatigue may occasionally occur fracture.

Sterilization is by autoclaving

Ideal ophthalmic suture needles

enough

rigidity to prevent easy

bending
sufficient length
sufficient diameter to create a tract
for the suture knot to be buried
as atraumatic as possible

Suture needles
All needles are made of stainless steel
the suture is swedged or glued onto the
needle

A suture needle has 5 geometries

Length - distance of the circumference from the
swage to the point
Chord length - distance of the straight line from the
swage to the point (which determines the width of the
bite)
Radius- length of the line from the center of the
circle
Needle diameter - measured in mils (1/1000 of an
inch) and 1 mil is about 25 um ,a smaller diameter
needle required less force and cause less trauma
during passage through the tissue
Bicurve - two radii on a needle, the radius near the
point is usually shorter than the radius of the body
near the swage

SELECTION OF SUTURE
MATERIALS/NEEDLES
Depends on:
composition and properties of the Suture
material,
task ahead,
surgeons choice,
Diameter of the suture material,
Effect of inserting the suture into the
tissue

Surgical needles are composed of 3

anatomic parts;
- The Swage
the thickest portion of the needle and the

portion to which the suture material is

attached

- Body
the mid portion of the needle.

- Point: cutting or reverse cutting

the sharpest portion and is used to penetrate
the tissue

Types of needles
Grouped

into four main types according

to the point configuration (i.e.. the
shape of the point):
cutting
reverse cutting
taper point
spatula

Types of needles
CUTTING

triangular
cuts at tips and edgesof the needle
may pull out tissue during needle passage

Types of needles
REVERSE

CUTTING

triangular with cutting edge at the bottom

cuts at tips and edges of needle
ideal for oculoplasticsurgery as the needle
allows easy passage through epidermis
accidental perforationmay occur with
partialthickness suture suchas rectus scleral
fixation

Types of needles
TAPER

POINT

round and taper toa point,

cuts at the tip only
atraumatic, produces the smallest hole of all
needles,
useful in iris repair

Types of needles
SPATULA

4 or 6 sided with cutting edges on theside

cuts at tip and sides parallel to the tissue
plane
allows needle to splitthe tissue plane and
avoid accidental perforation
most commonly usedneedle for anterior
segment surgery.

CONCLUSION