TECHNIQUE

Tri-soft shell technique

Steve A. Arshinoff, MD, FRCSC, Richard Norman, BSc, MASc
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Soft-shell techniques exist for lower viscosity dispersive with higher viscosity cohesive
ophthalmic viscosurgical devices (OVDs) (soft-shell technique [SST]), viscoadaptive OVDs with
balanced salt solution (ultimate soft-shell technique), intraoperative floppy-iris syndrome (soft-
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shell bridge), and many specific modifications for disinserted zonular fibers, frayed iris strands,
Fuchs endothelial dystrophy, small holes in the posterior capsule with protruding vitreous,
capsular dye use, and others. Soft-shell techniques exist because it is rheologically impossible
to control the surgical environment with a single OVD as well as with an ordered combination
of rheologically different OVDs. Surgeons frequently confuse these techniques because of their
multitude. This paper unifies all SSTs into a single improved tri-soft shell technique (TSST),
from which basic specific applications to unusual circumstances are simple and intuitive. As
shown with previous SSTs, the TSST allows surgeons to perform complex tasks with greater
surgical facility and to protect endothelial cells better than with single OVDs.
Financial Disclosure: Dr. Arshinoff has acted as a paid consultant to many global ophthalmic vis-
cosurgical device manufacturers, including all of those whose products are referred to in this article.
Neither author has a financial or proprietary interest in any material or method mentioned.
J Cataract Refract Surg 2013; 39:1196–1203 Q 2013 ASCRS and ESCRS
Supplemental material available at [Link].

The introduction of ophthalmic viscosurgical devices tailor the selection and use of OVDs to prevent those
(OVDs) with sodium hyaluronate (Healon), patented complications in even the most complex cataract
by Balazs in 19791 and first described for use in cata- surgeries.
ract surgery by Miller and Stegmann in 1980,2 revolu- The tri-soft shell approach is a generalization of
tionized anterior segment surgery. Prior to this, previously described soft-shell techniques (SSTs) to
damage to the corneal endothelium was an inevitable enhance and conceptually simplify a system of
consequence of intraocular surgery, particularly intra- rational OVD choices and use for different types of
ocular lens (IOL) implantation. The incorporation of cases. Each of the preceding SSTs used 2 OVDs in
OVDs into cataract surgery made it possible to protect distinct spatially adjacent shells within the anterior
the endothelium while simultaneously facilitating IOL chamber. Partitioning spaces in this way makes it
implantation by creating space. Since then, the range possible to create different adjacent physical environ-
of OVDs has expanded and our understanding of their ments within a single space, with rheological proper-
rheological properties and optimal techniques for use ties in each subspace chosen to best achieve the
has improved dramatically. It is now possible to intended goal(s) for that subspace. Generally, no single
design routine cataract procedures to minimize the fluid can achieve the same performance as 2 or more
risk for most possible complications and when poten- fluids exhibiting different properties used together in
tial problems are anticipated in a specific case, one can this manner. The single most important constraint is
that the OVD fluids must not mix or dilute one another
significantly during the surgical period. A brief sum-
Submitted: March 1, 2013. mary of these techniques illustrates this.
Accepted: March 5, 2013.

From York Finch Eye Associates, Humber River Hospital (Arshin-

off), University of Toronto (Arshinoff, Norman), Toronto, and PREVIOUS SOFT-SHELL TECHNIQUES
McMaster University (Arshinoff), Hamilton, Ontario, Canada. Dispersive–Cohesive Ophthalmic Viscoelastic Device
Corresponding author: Steve A. Arshinoff, MD, FRCSC, York Finch
Soft-Shell Technique
Eye Associates, 2115 Finch Avenue West, #316, Toronto, Ontario, The first SST, the dispersive–cohesive OVD SST,
Canada M3N 2V6. E-mail: ifix2is@[Link]. was described in 1999.3 As the name implies, this

1196 Q 2013 ASCRS and ESCRS 0886-3350/$ - see front matter

Published by Elsevier Inc. [Link]
 TECHNIQUE: TRI-SOFT SHELL 1197

technique combines 2 OVDs, a lower-viscosity disper- transmitted through the vitreous), the SST uses a
sive OVD and a higher-viscosity cohesive OVD, into high-viscosity cohesive OVD to create space during
an outer and inner shell, respectively. (Note that for surgery and to stabilize tissues. Cohesive OVDs have
classification of an OVD, the viscosity or resistance the advantage of being easier to remove at the comple-
to deformation by an imposed shear stress refers to tion of surgery, as their tendency to avoid breaking
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the zero-shear viscosity [ZSV] or viscosity when the apart permits them to be aspirated by I/A easily in a
OVD is at rest; the pseudoplastic nature of all OVDs single cohesive but deformable, supple mass. The
means that their viscosity decreases with increasing high viscosity of higher-viscosity cohesive OVDs is
imposed shear rate, making ZSV the only consistent what facilitates pressurization and stability of the ante-
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repeatedly measureable viscosity value [Table 1, rior chamber during surgery, as it is the viscosity of the
Figure 1]).4 OVD adjacent to the incisions that determines the limit
Dispersive OVDs tend to fragment on their surface of possible pressurization of the entire anterior cham-
when exposed to moderate shear stress (eg, aspiration ber, regardless of what lies behind it, beyond which
with an irrigation/aspiration [I/A] device), making the OVD blockade of incisional leakage fails.
them comparatively resistant to aspiration. This has In the SST, the increased retention of a dispersive
been confirmed experimentally, with thicker retained OVD is used to isolate peripheral structures (eg,
OVD layers remaining adjacent to endothelial cells corneal endothelium, vitreous, or iris) behind a protec-
observed more with dispersive OVDs than with cohe- tive layer of dispersive OVD, which has been posi-
sive OVDs during simulated phacoemulsification.5 tioned into a smooth thin layer by the pressure of a
Because lower-viscosity dispersive OVDs are poor viscous–cohesive OVD (Figure 2). After phacoemulsi-
at space creation (by definition, they lack the ability fication and I/A of residual lenticular cortex have been
to resist significant stresses such as those imposed dur- completed, the second step of the SST takes advantage
ing surgical manipulation or by the posterior pressure of the low-viscosity nature of the dispersive OVD to
originating from the extraocular muscles and facilitate IOL implantation by creating a central lake

Table 1. Classification of OVDs 2013

V0 (zero-shear viscosity) Cohesive OVDs Dispersive OVDs

range (mPa.s) CDI R 30 (%asp/mm Hg) CDI ! 30 (%asp/mm Hg)

7–18 x 106 (ten millions) Viscoadaptives

Healon5, iVisc (MicroVisc),
Phaco BD MultiVisc
1–5 x 106 (millions) Higher-viscosity cohesives Higher-viscosity dispersives
Super viscous cohesives Super viscous dispersives
Healon GV, iVisc (MicroVisc, None
HyVisc) Plus,BD Visc,
AcriHylon Plus
105–106 (hundred thousands) Viscous cohesives Viscous dispersives
Healon, iVisc (MicroVisc, DisCoVisc
HyVisc), Eyefill HC, Amvisc Plus
Ophthalin Plus, Provisc,
Opegan Hi, Biolon Prime,
Biolon, Amvisc, Ophthalin,
Eyefill SC
104–105 (ten thousands) Lower-viscosity cohesives Lower-viscosity dispersives
Medium viscosity cohesives Medium viscosity dispersives
None Viscoat, Biovisc, Endogel,
Rayvisc, Opelead, Vitrax,
Healon D, Healon Endocoat,
Cellugel, Eyefill HD
103–104 (thousands) Very low viscosity cohesives Very low viscosity dispersives
None Opegan, OccuCoat, Icell,
many more HPMCs
100 Aqueous solutions

HPMC Z hydroxypropyl methylcellulose; mPa.s Z millip[[Link]; CDI Z cohesion–dispersion index

*Available in USA

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 1198 TECHNIQUE: TRI-SOFT SHELL

incision by a cartridge stabilizes the anterior chamber

and reduces reliance on mechanical OVD properties,
permitting the surgeon to use the OVD in the anterior
chamber for an alternate function, such as lubrication
of the posterior capsule or protection of a predeter-
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mined site (eg, protruding vitreous).

Several studies have experimentally validated the
SST, finding less increase in postoperative central
corneal thickness and less endothelial cell loss, even
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with dense cataracts and Fuchs endothelial dystrophy,

than with the use of a single OVD.6–8

Ultimate Soft-Shell Technique

With the advent of viscoadaptive OVDs (eg, sodium
hyaluronate 2.3% [Healon5] and sodium hyaluronate
Figure 1. Pseudoplasticity curves of common OVDs. The log–log 2.5% [iVisc Phaco]), new SSTs became possible. These
plot of OVD viscosities versus imposed shear rate performed in a OVDs exhibit super viscous–cohesive behavior under
rheometer. Note that every OVD found to be clinically useful is low shear stress (flow rates less than about 25 cc/min)
pseudoplastic in its rheological behavior, meaning that viscosity
but become fracturable solids, recalling the dispersive
decreases with increasing shear rate, but when shear rate is continu-
ally decreased, a limiting viscosity is eventually reached, below behavior of lower-viscosity dispersive OVDs at higher
which viscosity is fairly constant (curve becomes horizontal). The flow rates (termed pseudodispersive behavior).4,9 The
top curve ( iVisc phaco), however, appears not to flatten out to hor- extremely high viscosity of viscoadaptive OVDs at low
izontal at low shear. If this behavior were to continue indefinitely as flow rates was an extraordinary benefit to cataract sur-
shear rate is continually decreased, the ZSV of iVisc phaco would
geons, but introduced new challenges10: (1) Capsulo-
become infinity and iVisc phaco would become solid, no longer a
liquid, and its behavior would be referred to as plastic instead of rhexis is more difficult when the capsular flap has to
pseudoplastic. Also note that the rheologic behavior of water is be dragged through a highly viscous viscoadaptive
constant irrespective of shear rate,and therefore referred to as OVD–filled anterior chamber. (2) Hydrodissection is
Newtonian. Note that the viscosity of water at all shear rates is 1 more difficult when the wound is blocked by an ante-
mPa∙s, 10 000-fold less than the least viscous OVD.
rior chamber overfilled with a viscoadaptive OVD.
When balanced salt solution is injected under the cap-
of lower-viscosity dispersive OVD enclosed within a sulorhexis, into the capsular bag, the pressure in the
shell of higher-viscosity cohesive OVD (Figure 2). anterior chamber can rise and the chamber can deepen
This makes instrument manipulation and IOL unfold- excessively if a pathway for balanced salt solution
ing easier, while the peripheral structures (iris and egress has not been created. (3) The initial cases done
corneal endothelium) remain stationary and undis- in Finland using Healon5 were performed without
turbed. This second step is currently used less instruction for complete removal and therefore some
frequently because of the advent of IOL injector patients developed extremely high postoperative
cartridges, which eliminate the introduction of the intraocular pressure (IOP) spikes. Reports to the
IOL folding forceps into the anterior chamber and manufacturer from these initial cases led many sur-
seal the incision as the IOL is injected. Sealing the geons to avoid using this OVD even though IOP spikes

Figure 2. Relationship of SSTs. For each technique, the soft-shell configuration prior to the initiation of phacoemulsification and prior to IOL
insertion is illustrated. The TSST is a generalization of previously described SSTs and can be easily modified to resemble each depending on
the requirements of a particular surgery (SST Z soft-shell technique; USST Z ultimate soft-shell technique; SSB Z soft-shell bridge; TSST Z
tri-soft shell technique).

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 TECHNIQUE: TRI-SOFT SHELL 1199

were a well-known complication encountered with the turned on to remove residual OVD. Because the IOL
first OVD products such as Healon. This issue was pre- is inserted under an OVD shell into balanced salt solu-
viously resolved with the use of removal techniques tion, minimal OVD remains behind the IOL, removing
such as the rock ‘n’ roll and others.11 Instruction for the need for potentially dangerous manipulation of the
removal of Healon5 was all that was required. IOL to remove residual OVD. The 2-compartment
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One major advantage of viscoadaptive OVDs is technique of Tetz and Holzer14 can be used to go
their ability to more effectively blockade incisions, behind the IOL, but it is rarely needed. With this final
making it possible to seal much less viscous soft- step, the USST has addressed all 3 concerns of visco-
shell partner fluids (even as low a viscosity partner adaptive OVD use listed above.
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fluid as water) within the anterior chamber behind

the viscoadaptive OVD. This fact enhanced soft-shell Modifications of Soft-Shell Technique and Ultimate
possibilities because the more the rheological proper- Soft-Shell Technique for Special Cases
ties of the 2 OVDs used in an SST differ, the more effec-
As familiarity with SSTs has increased, further
tive the technique can be.12,13 Thus arose the ultimate
adaptations have been made to tailor their use to spe-
soft-shell technique (USST), extending this ability to
cific intraoperative problems. For example, in cases of
its practical limit by pairing a viscoadaptive OVD
white or brunescent cataracts, the USST can be modi-
with balanced salt solution, which has a viscosity of
fied to enhance visualization of the anterior capsule
only 100 or 1 millipascal-second (mPa∙s), the same as
through the addition of trypan blue into only the
water.10 For comparison, the ZSV of viscoadaptive
balanced salt solution zone created directly adjacent
OVDs are on the order of 107 mPa∙s. This dramatic dif-
to the anterior lenticular surface.15,16 This approach al-
ference in rheological properties allows the creation of
lows targeted staining of the anterior capsule, while
2 completely different physical environments within
the remainder of the anterior chamber is sequestered
the anterior chamber.
by the viscoadaptive OVD, maintaining excellent visu-
The outer shell of a viscoadaptive OVD is used to
alization and stability of surrounding structures.
coat the corneal endothelium, physically isolating it
In cases of a broken zonule and frayed iris strands,
from fluid turbulence and ultrasonic energy, while
the SST can be modified by using additional dispersive
blocking the incision to ensure good pressurization
OVD to encase the damaged structure, isolating and
of the anterior chamber. Balanced salt solution, often
supporting it within a layer of dispersive OVD.17
containing a pharmacologic agent (trypan blue, lido-
This technique can be enhanced if a viscoadaptive
caine, phenylephrine, or a combination of lidocaine
OVD is substituted for the higher viscosity cohesive
and phenylephrine [Appendix, available at http://
OVD because the rheological difference between the
[Link]] are the most common) is then injected
2 OVDs becomes greater.
onto the lens surface below the OVD to create a low-
Another extension of SSTs has been described for
viscosity working space, solving challenges 1 and 2
managing cases of intraoperative floppy-iris syn-
outlined above (Figure 2). The balanced salt solution
drome (IFIS) in patients taking the a-1A antagonist
layer also provides an easy egress path for injected
tamsulosin (Flomax). In this case, the SST and USST
balanced salt solution during hydrodissection, espe-
approaches are combined into a procedure referred
cially if the hydrodissection cannula is wiggled as it
to as the soft-shell bridge (SSB) using a peripheral
is inserted into the phaco incision, breaking any
low-viscosity dispersive OVD shell tamponading the
OVD structure at the incision.10
iris, resisting aspiration and preventing iris flutter
A similar soft-shell arrangement is also created dur-
and propensity for prolapse commonly seen in IFIS,
ing IOL insertion, with an outer layer of viscoadaptive
while the pupil is dilated and the central anterior
OVD filling the anterior chamber entirely or partially
chamber stabilized with a bridge of viscoadaptive
(in the area of the incision and extending partially
OVD and a working space is created adjacent to the
into the anterior chamber) and an inner layer of
lenticular surface with balanced salt solution or prefer-
balanced salt solution within the capsular bag
ably a lidocaine–phenylephrine solution.18 The phaco-
(Figure 2). The leading IOL haptic unfolds easily
emulsification takes place as usual, using lower flow
once it enters the low-viscosity balanced salt solution
parameters within the balanced salt solution zone,
environment of the bag. After the IOL injector is
sequestered by the viscoadaptive OVD layer in the
removed, the I/A device is promptly inserted into
central region of the anterior chamber (Figure 2).
the anterior chamber, and when the irrigation is
turned on, the IOL begins to fall backward into the
balanced salt solution–filled capsular bag. Gentle TRI-SOFT SHELL TECHNIQUE
nudging of the still folded trailing haptic with the Based on the various soft-shell approaches, an
I/A tip positions the IOL in the bag as aspiration is enhanced generalized soft-shell approach, the tri-soft

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 1200 TECHNIQUE: TRI-SOFT SHELL
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Figure 3. Tri-soft shell technique. A dispersive OVD is first injected centrally on the surface of the lens (A). A viscoadaptive OVD is then injected
beneath this initial shell (B), displacing it upward into a smooth layer coating the endothelium of the cornea (C). Balanced salt solution is injected
onto the anterior capsule surface, below the OVDs, creating a low-viscosity work area for capsulorhexis (D). After phacoemulsification and I/A
of the lens, the viscoadaptive OVD shell is rebuilt as needed beginning at the corneal incision, with the goal of blocking the incision and creating a
roof over the capsular bag to protect the corneal endothelium (E). Balanced salt solution is injected through the viscoadaptive OVD into the
capsular bag, creating an OVD-free space in which the IOL's leading haptic can be placed and unfolded (F).

shell technique (TSST), has been developed. This tech- viscoadaptive OVD that pressurizes and stabilizes
nique can be more easily conceptually modified to the inner shell.
adapt to any of the scenarios described above and Balanced salt solution or lidocaine–phenylephrine is
others (Figure 3). It is more effective and has a broader then injected slowly beneath the viscoadaptive OVD
range of efficacy than older SSTs and is well-suited to layer, with the cannula aperture directed downward
the most complex cataract surgeries; for example, a pa- toward the lens surface (Figure 3, D). This creates a
tient with severe Fuchs endothelial dystrophy and IFIS, continuous lake of low-viscosity fluid directly on the
where maximal control over the operative environment lenticular surface, with the pupillary margin serving
is desired. In less complex cases, structural elements of roughly as its peripheral border. The viscoadaptive
the tri-soft shell can be modified or omitted, simplifying OVD shell has been displaced upward, creating a cen-
the procedure (Figure 2). With this paradigm for OVD tral bridge. Now, a variant of the USST has been
use in mind, the surgeon is able to easily customize his created below the SST, hence the name tri-soft shell.
or her approach to a patient's individual needs. A routine capsulorhexis is performed using a bent
The TSST is performed as follows: After the side- needle or forceps, with a bent needle being less likely
port incision is created, the eye is anesthetized and to disturb the OVD shells. Because this takes place
pressurized and the pupil dilated using 0.1 to 0.2 cc within the low-viscosity balanced salt solution lake,
of a xylocaine–phenylephrine mixture injected intra- minimal resistance is encountered when the instru-
camerally. A 2.2 mm phaco incision (or other size ments or capsular flap are manipulated. The capsulo-
based on the intended phaco machine) is then created. rhexis diameter should be kept slightly smaller than
The dispersive OVD (eg, chondroitin sulphate that of the pupil to isolate the iris from turbulence dur-
4%–sodium hyaluronate 3% [Viscoat]) is injected ing the ensuing phacoemulsification procedure.
through the phaco incision to form a central mound Hydrodissection is performed using balanced salt
on the surface of the anterior capsule, stopping once solution in a 10 cc syringe with a 27-gauge Chang can-
the anterior chamber is about 20% to 25% full nula (Katena Products, Inc.). Careful injection of the
(Figure 3, A). A viscous–cohesive OVD, or preferably balanced salt solution will allow it to circulate around
a viscoadaptive OVD to maximize the viscosity differ- the lens, underneath the viscoadaptive OVD shell, and
ence, is then injected beneath the dispersive OVD onto out of the eye through the phaco incision without dis-
the surface of the anterior capsule (Figure 3, B). This turbing the shells. Occasionally during hydrodissec-
displaces the Viscoat shell upward against the endo- tion, the shells may be disrupted and OVD will be
thelial surface of the cornea, creating a smooth contin- lost. In this case, it is always the viscoadaptive OVD
uous dispersive shell (Figure 3, C). Injection of the layer that is lost. If this occurs, simply reinject the vis-
viscoadaptive OVD should continue until the pupil coadaptive OVD followed by the balanced salt solu-
stops dilating but before the eye becomes firm. At tion layer below it before proceeding.
this point, a variant of the SST has been formed During the subsequent phaco procedure, the
composed of a low-viscosity protective outer layered OVD shells are preserved better with lower
dispersive OVD shell encircling a cohesive or a flow rates. The senior author (S.A.A.) routinely uses

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 TECHNIQUE: TRI-SOFT SHELL 1201

a flow rate of 32 cc/min, a bottle height of 95 cm above ZSVs 3 or more log units lower than viscoadaptive
the patient's eye, and a vacuum limit of 330 mm Hg. In OVDs but only 1 log unit lower than viscous-
a patient with IFIS or Fuchs endothelial dystrophy, the cohesive OVDs. As stated above, maximizing the
machine settings are reduced to a flow rate of 15 to viscosity difference between 2 fluids reduces their
25 cc/min, vacuum of 200 to 250 mm Hg, and bottle propensity to mix.12,13 This concept is already used
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height of 75 to 80 cm, with lower parameters in the by the SST but is greatly enhanced in the TSST,
most severe cases. ensuring retention of the dispersive OVD layer to pro-
Once the I/A has been completed, IOL insertion can tect the endothelium.
proceed as described for the USST above. For IOL im- Careful control over the middle viscoadaptive OVD
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plantation, as more experience is gained, viscoadap- shell is most important in the TSST as it plays the
tive OVD blockade of the incision and only the area central role in facilitating the proposed surgery. The
of the capsulorhexis near the incision will be all that viscoadaptive OVD layer is responsible for 4 mechan-
is necessary, with the remainder of the anterior cham- ical roles: space creation in and pressurization of the
ber and capsular bag filled with balanced salt solution anterior chamber, incisional blockade, and tamponade
injected through the viscoadaptive OVD into the of peripheral structures including the dispersive OVD
capsular bag in a manner similar to that used during shell, which itself tamponades iris and any exposed
hydrodissection using a hockey-stick cannula vitreous. Viscoadaptive OVDs are ideal for this role
(Figure 3, E and F). The IOL is then inserted using an because of their extremely high ZSV, causing them to
injector cartridge. The I/A is inserted into the eye resist deformational stresses imposed on the eye
and turned on; slight posterior nudging of the trailing during surgery. Because of their exceptional ability
haptic and IOL is exerted, causing the IOL to fall back- for incisional blockade, viscoadaptive OVDs allow
ward into the balanced salt solution–filled capsular the introduction of a balanced salt solution layer adja-
bag and open. The OVD is removed using I/A, taking cent to the lenticular surface, facilitating capsulorhexis
only a few seconds; this is usually complete once the by creating a region of minimal viscosity and hence
surgeon realizes that the IOL has fallen backward minimal resistance to delicate manipulation, while
into the capsular bag. When preoperative endothelial the viscoadaptive OVD shell creates a bridge to fix
cell counts are marginal, the surgeon may elect to leave the peripheral anatomical structures in place.
the dispersive OVD layer in the eye by keeping the I/A Including the balanced salt solution shell in the tech-
posteriorly, avoiding exposure of the endothelium to nique provides marked benefits. It allows the localized
turbulence.17 delivery of agents such as trypan blue to the capsule or
lidocaine and phenylephrine to the iris. The shallow
depth of the balanced salt solution layer both avoids
DISCUSSION the clouding that can occur when trypan blue is intro-
The TSST maximizes the surgeon's control over the duced into the entire anterior chamber and reduces the
operative field by leveraging the impressive range of potential for toxicity of any agent added to this space,
physical properties available from modern OVDs. Un- as only an extremely small quantity is required for full
derstanding the physical underpinnings of this effect. The sequestered balanced salt solution shell also
approach makes it apparent how combining multiple facilitates phacoemulsification, as the working space is
OVDs can lead to greater surgical precision and restricted to a relatively small volume directly adjacent
control. to the lens. This small volume allows the creation of
As with the original SST, the TSST uses a thin disper- considerable desired turbulence at comparatively
sive OVD shell to protect the corneal endothelium. low pump settings (eg, 15 cc/min), as the ratio of
Ophthalmic viscosurgical device retention has been flow rate to working volume is dramatically higher
linked both theoretically and experimentally to greater than if flow were higher but directed throughout the
dispersive properties, negative charge, and a composi- entire anterior chamber. Put simply, it will feel as
tion including hyaluronic acid, making the selection of though the pump is set at a higher setting, making it
a dispersive OVD such as Viscoat ideal when endo- easier to draw material to the phaco tip. This can be
thelial cell protection is a priority.5,17,19,20 A key modi- understood intuitively by comparing using a garden
fication of the TSST from the SST is that it pairs the hose to fill a bucket and a swimming pool: The same
dispersive OVD shell with a viscoadaptive OVD flow rate in the smaller volume induces much greater
rather than a viscous–cohesive OVD for enhanced turbulence. Besides making surgery more straightfor-
space creation and stability. ward, this compartmentalized flow effectively isolates
Compared with traditional viscous cohesive OVDs, vulnerable endothelial cells from turbulence. Low
viscoadaptive OVDs have ZSVs approximately 2 log flow rates (below approximately 25 cc/min) typically
units greater.4 In comparison, dispersive OVDs have do not develop sufficient turbulence at the perimeter

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 1202 TECHNIQUE: TRI-SOFT SHELL

of the balanced salt solution space to fracture the mo- Regardless of these changes, however, the physical
lecular structure of the viscoadaptive OVD, resulting principles underlying soft-shell methods and their
in a continuous shell overlying the balanced salt solu- generalizable enhancement to the TSST will continue
tion layer throughout surgery.4,9,10 to be valid, and thus the framework outlined here
We have also investigated the relationship between can be used to guide the selection and application of
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the ZSV of an OVD and the cohesion–dispersion OVDs in all anterior segment surgeries and complica-
index,21 an objective measure of an OVD's behavior tion management.
under vacuum aspiration, as cohesive OVDs tend to
aspirate in a bolus fashion while dispersive OVDs
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tend to aspirate in a gradual fashion. The findings sug- WHAT WAS KNOWN
gest that viscoadaptive OVDs may be retained well in  The basic SST is the most common combination OVD
the anterior chamber at the shear rates imposed during technique used globally. Its numerous adaptations to spe-
phacoemulsification when appropriate settings are cific problems are frequently accompanied by confusion.
used by occupying a transition point between solid
and fluid physical behaviors, thereby behaving as
fluids during their injection but as solids during sur- WHAT THIS PAPER ADDS
gery.9,A,B A final benefit of the use of balanced salt so-  The amalgamation of all SSTs into a single method en-
lution in the TSST occurs when the IOL is inserted, hances all the techniques, simplifies them conceptually
because the lens is placed in balanced salt solution for the surgeon, and makes adaptations for specific situ-
rather than in an OVD. The risk for retained OVD ations far more intuitive.
behind the lens and ensuing postoperative IOP spikes
is thus reduced.
The TSST is meant to be a paradigm of rheological
principles to guide the use of multiple OVDs in concert REFERENCES
to enhance surgery and protect adjacent delicate tis- 1. Balazs EA, inventor; Bioptrics, Inc., assignee. Ultrapure hyalur-
sues form the side effects of phacoemulsification. It is anic acid and the use thereof. US patent 4 141 973. February 27,
not meant to be a cookie-cutter solution to cataract 1979.
2. Miller D, Stegmann R. Use of Na-hyaluronate in anterior
surgery. The surgeon should use his or her clinical segment eye surgery [editorial]. Am Intra-Ocular Implant Soc J
intuition to guide the use of OVDs in a given case. 1980; 6:13
For example, in cases of white or brunescent cataract, 3. Arshinoff SA. Dispersive-cohesive viscoelastic soft shell tech-
trypan blue may be painted over the lenticular surface nique. J Cataract Refract Surg 1999; 25:167–173
before the balanced salt solution injection to enhance 4. Arshinoff SA, Jafari M. New classification of ophthalmic
viscosurgical devicesd2005. J Cataract Refract Surg 2005;
visualization. In intumescent mature cataracts, the 31:2167–2171
anterior capsule should be seen to become centrally 5. Petroll WM, Jafari M, Lane SS, Jester JV, Cavanagh HD. Quan-
concave to prevent the Argentinean flag sign.C In titative assessment of ophthalmic viscosurgical device retention
IFIS cases, lidocaine–phenylephrine solution makes a using in vivo confocal microscopy. J Cataract Refract Surg 2005;
big difference by ensuring maximal pupillary dilation 31:2363–2368
6. Miyata K, Nagamoto T, Maruoka S, Tanabe T, Nakahara M,
and iris tone. In an uncomplicated cataract, the full Amano S. Efficacy and safety of the soft-shell technique in cases
TSST may not be necessary; instead, for example, the with a hard lens nucleus. J Cataract Refract Surg 2002;
dispersive OVD layer can be eliminated when only a 28:1546–1550
brief phaco time is anticipated. The USST is the natural 7. Tarnawska D, Wylega1a E. Effectiveness of the soft-shell tech-
result of such omission of dispersive OVD use in the nique in patients with Fuchs’ endothelial dystrophy. J Cataract
Refract Surg 2007; 33:1907–1912
TSST, eliminating some steps and reducing cost. If a 8. Van den Bruel A, Gailly J, Devriese S, Welton NJ, Shortt AJ,
patient has severe IFIS, a little more dispersive OVD Vrijens F. The protective effect of ophthalmic viscoelastic
is injected and care is taken to cover the iris well, devices on endothelial cell loss during cataract surgery: a
resulting in the SSB. If there are broken zonular fibers, meta-analysis using mixed treatment comparisons. Br J Oph-
the dispersive OVD layer is spread to cover the area of thalmol 2011; 95:5–10
9. Arshinoff SA, Wong E. Understanding, retaining, and removing
broken fibers and protruding vitreous. Once the dispersive and pseudodispersive ophthalmic viscosurgical
surgeon becomes familiar with the TSST, simple devices. J Cataract Refract Surg 2003; 29:2318–2323
modifications become obvious for the management 10. Arshinoff SA. Using BSS with viscoadaptives in the ultimate
of specific problems, making OVD use conceptually soft-shell technique. J Cataract Refract Surg 2002; 28:1509–
easier and more effective in all cases. 1514
11. Arshinoff SA. Rock ‘n’ roll removal of Healon GV. In: Arshinoff SA,
Surgeon preference and continued progress in OVD ed, Proceedings of the 7th Annual National Ophthalmic Speakers
development may motivate the selection of alternative Program, Ottawa, June 1997. Quebec, Canada, Medicopea,
OVDs for 1 or more components of the TSST. 1997; 29–30

J CATARACT REFRACT SURG - VOL 39, AUGUST 2013

 TECHNIQUE: TRI-SOFT SHELL 1203

12. Burmester SSH, Rielly CD, Edwards MF. The mixing of miscible 20. Poyer JF, Chan KY, Arshinoff SA. New method to measure the
liquids with large differences in density and viscosity. In: King R, retention of viscoelastic agents on a rabbit corneal endothelial
ed, Fluid Mechanics of Mixing: Modeling, Operations, and cell line after irrigation and aspiration. J Cataract Refract Surg
Experimental Techniques (Fluid Mechanics and its Applications, 1998; 24:84–90
vol. 10) [Papers presented at the 7th European Congress on 21. Poyer JF, Chan KY, Arshinoff SA. Quantitative method to deter-
Mixing, September 1991, Brugge, Belgium]. Boston, MA, Kluwer mine the cohesion of viscoelastic agents by dynamic aspiration.
Downloaded from [Link] by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW

Academic Publishers, 1992; 83–90 J Cataract Refract Surg 1998; 24:1130–1135

€
13. Regner M, Ostergren €gårdh C. Influence of viscosity ratio
K, Tra
on the mixing process in a static mixer: numerical study. Ind Eng OTHER CITED MATERIAL
Chem Res 2008; 47:3030–3036 A. Arshinoff S, Jafari M, Koushan, K, “OVD Use Enhanced by
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 06/20/2024

14. Tetz MR, Holzer MP. Two-compartment technique to remove Cohesion Data,” poster presented at the ASCRS Symposium
ophthalmic viscosurgical devices. J Cataract Refract Surg on Cataract, IOL and Refractive Surgery, San Francisco,
2000; 26:641–643 California, USA, March 2006
15. Arshinoff S. Capsule dyes and the USST [letter]. J Cataract B. Arshinoff S. “Understanding OVDs Course 14-107,” given at the
Refract Surg 2005; 31:259–260 ASCRS Symposium on Cataract, IOL and Refractive Surgery,
16. Marques DMV, Marques FF, Osher RH. Three-step technique Chicago, Illinois, USA, April 2012
for staining the anterior lens capsule with indocyanine green or C. Perrone DM, “Argentinean Flag Sign,” video presented at the
trypan blue. J Cataract Refract Surg 2004; 30:13–16 ASCRS Symposium on Cataract, IOL and Refractive Surgery,
17. Arshinoff SA. Ophthalmic viscosurgical devices. In: Kohnen T, Boston, Massachusetts, USA, May 2000
Koch DD, eds, Cataract and Refractive Surgery (Essentials in
Ophthalmology Series). Berlin, Germany, Springer-Verlag,
2005; 37–62
First author:
18. Arshinoff SA. Modified SST–USST for tamsulosin-associated
intraocular floppy-iris syndrome. J Cataract Refract Surg 2006; Steve A. Arshinoff, MD, FRCSC
32:559–561; erratum, 1076 York Finch Eye Associates, Toronto,
19. McDermott ML, Hazlett LD, Barrett RP, Lambert RJ. Visco- Ontario, Canada
elastic adherence to corneal endothelium following
phacoemulsification. J Cataract Refract Surg 1998; 24:678–
683

J CATARACT REFRACT SURG - VOL 39, AUGUST 2013