In an adult patient without glaucoma or corneal disease undergoing implantable collamer lens implantation, what is the most effective method to remove viscoelastic material at the end of surgery?

Effective Viscoelastic Removal in ICL Implantation

The most effective approach is to eliminate viscoelastic use entirely through the OVD-free (pure) ICL implantation technique, which uses balanced salt solution (BSS) for lens loading and anterior chamber maintenance, completely avoiding viscoelastic-related complications while reducing surgical time and improving early postoperative outcomes. 1, 2

Evidence for OVD-Free Technique

The OVD-free method has demonstrated superior safety and efficiency compared to traditional viscoelastic-based approaches:

• No postoperative IOP elevation: Zero eyes (0%) experienced IOP >22 mmHg at 2 hours post-surgery with OVD-free technique versus 20% with traditional viscoelastic use 2
• Faster visual recovery: Significantly better uncorrected and corrected visual acuity at 1 day postoperatively compared to traditional technique 2
• Shorter surgical time: Mean operative time of 2.9 minutes versus 4.4 minutes with viscoelastic (P<0.001) 1, 2
• Equal endothelial safety: No significant difference in endothelial cell density loss between techniques at 2-year follow-up (1.9% OVD-free vs 2.3% with OVD) 1

OVD-Free Surgical Technique

Lens Loading and Implantation

• Load the ICL using BSS instead of viscoelastic material 1, 2
• Maintain the anterior chamber with BSS irrigation throughout the procedure 1, 3
• Insert the ICL through the standard incision with continuous BSS flow 2

Anterior Chamber Management

• Use balanced salt solution to maintain chamber depth and stability during lens positioning 1, 3
• Ensure adequate BSS flow to prevent chamber collapse without requiring viscoelastic support 2

If Traditional Viscoelastic Technique Is Used

When viscoelastic must be used (surgeon preference or complex cases), complete removal is critical:

Removal Technique

• Use automated irrigation/aspiration immediately after lens implantation 4
• Sodium hyaluronate (Healon, Healon GV) removes most efficiently: Complete removal within 20-25 seconds with automated I/A 4
• Cohesive viscoelastics are easier to remove than dispersive types 4

Critical Removal Points

• Aspirate viscoelastic from behind the ICL optic, as material trapped in this space may cause IOP elevation 4
• Dispersive viscoelastics (like Viscoat) adhere to lens capsule and require approximately 3.5 minutes for complete removal 4
• Ensure thorough removal from all anterior chamber spaces, not just the central area 4

One-Step Viscoelastic Technique (Alternative)

If viscoelastic is preferred but concerns about removal exist:

• The one-step technique minimizes viscoelastic volume while maintaining surgical safety 5
• IOP returns to baseline by 1 day postoperatively with this modified approach 5
• Corneal endothelial parameters remain stable through 3-month follow-up 5

Key Advantages of OVD-Free Approach

Cost reduction: Eliminates expense of viscoelastic materials 1, 2

Improved early outcomes: Better visual quality indices (MTF cut-off, Strehl ratio, OV20%) at 1 day postoperatively 2

No IOP-related complications: Completely eliminates the most significant complication of viscoelastic use 2

Equivalent long-term safety: No difference in cataract formation, macular degeneration, or vision-threatening complications through 2-year follow-up 1

Common Pitfall to Avoid

The primary error is assuming viscoelastic is necessary for ICL implantation safety. Multiple studies demonstrate that BSS alone provides adequate anterior chamber maintenance and lens protection while eliminating viscoelastic-related complications 1, 2. The traditional teaching that viscoelastic is mandatory for phakic IOL surgery has been superseded by evidence showing superior outcomes with the OVD-free technique.