Balanced salt solution

A balanced salt solution (BSS) is a solution made to

a physiological pH and isotonic salt concentration.
Solutions most commonly include sodium,
potassium, calcium, magnesium, and chloride.
Balanced salt solutions are used for washing tissues
and cells and are usually combined with other
agents to treat the tissues and cells. They provide
the cells with water and inorganic ions, while
maintaining a physiological pH and osmotic pressure
 Hypothermic Effect of BSS
Study Hypothermic effect of BSS

Jabbour et Decreased intraoperative bleeding, decreased fibrin production, and less

al (1988) postoperative reaction, generalized slowing of metabolism in the cooled
eye, including the slowing of enzymatic reactions such as fibrin
production perhaps because of vasoconstriction, increased platelet
clumping, increased vascular resistance, decreased blood flow, and
alternative clotting mechanisms
Kachilele et Adverse effects of hypothermia appear to be of two types, a general
al (1998) retardation of growth and differentiation (as indicated by reduced yolk
sac diameter, number of somites and protein content) and additional
effects on particular development processes such as turning and neural
tube closure

Joussen et The benefit of hypothermia during phacoemulsification remains

al (2000) questionable. Moderate hypothermia over a limited time does not
appear to cause corneal damage. There is no detectable effect of the
irrigating solution temperature
 Corneal Edema
• Definition: Swelling of the cornea. Though the term is often used loosely by
clinicians, corneal edema technically refers to a cornea hydrated beyond its
normal 78% water content
• Cause: Endothelial cell dysfunction or elevated IOP
• Pathology: The cornea is normally 78% water; corneal edema (with resultant
scattering of light and decreased transparency) occurs when this level of
hydration is increased to more than 5% above baseline. With corneal edema
secondary to endothelial cell dysfunction, it is typically only around a central
endothelial cell density of 500 cells/mm2 (down from normal life-time
averages of 5000 cells/mm2 to 2500 cells/mm2) that corneal edema manifests
clinically
• Symptoms: Blurry vision, haloes, pain (if corneal epithelial defects or bullae are
present)
• Signs: Stromal edema, epithelial edema, bullous epithelial changes, endothelial
corneal (Fuchs’) dystrophy (cornea guttata), abrasion, IOP may be elevated
Corneal Edema
 Corneal Edema
• Investigations
– History: note any history of ocular surgery (e.g. cataract surgery, LASIK) or trauma.
Check for history of amantadine use (for influenza or Parkinson’s treatment), which
has been implicated in inducing bilateral corneal edema in some patients
– Visual acuity test: usually decreased relative to severity of edema
– Slit-lamp examination: pigmented guttata often visible in Fuchs’ endothelial
dystrophy and microcystic epithelial edema, bullous changes on the corneal surface
are a sign of marked endothelial dysfunction. Carefully assess other eye for sign of
Fuchs’ dystrophy
– Pachymetry and/or specular/confocal microscopy: to confirm that corneal edema is
present, and to what degree
– Dilated fundus examination
• Complications
– Corneal abrasion/ruptured bullae
– Infectious corneal ulcer
– Angle-closure glaucoma
 Corneal edema
• Differential Diagnosis
– Interstitial keratitis
– Infectious keratitis
– Corneal dystrophy
– Corneal scar (inert)
• Management
– Diet and lifestyle  hair drier may be cautiously used to blow air on the cornea (not at high heat levels!)
to increase evaporation
– Hypertonic saline ointment (Adsorbonac or Muro 128 5% tid) can often improve or resolve epithelial
edema
– A broad-spectrum topical antibiotic (polimyxin B sulfate-trimethoprim (Polytrim) or tobramycin (Tobrex)
qid) is used to treat epithelial defects. Persistent defects or painful bullae may require a bandage contact
lens or tarsorrhapy
– A topical steroid (prednisolone acetate 1% up to qid) may be useful for stromal edema
– Treat underlying abnormality
– A penetrating keraoplasty (corneal graft/transplant) may be required
• Prognosis: depends on the underlying problem and the status of the corneal endothelium,
which is the natural pump that keeps the cornea clear and compact. If the endothelium is
healthy, then the edema usually resolves completely. However, corneas with reduced
endothelial cell counts may not able to recover from significant stresses and may fail
 Pachoemulsification
• Phacoemulsification as a surgical technique continues to advance
towards a less invasive surgery with better outcomes. There is a drive
towards smaller incisions, more exacting postoperative refractive
results, less trauma to intraocular structures, and management and
prevention of complications. Even manual extraction techniques of
cataract surgery are moving towards smaller incisions.
Phacoemulsification with foldable IOLs is undoubtedly the gold
standard wherever Phaco machines and trained surgeons are
available and the service affordable. Unfortunately, the technique
depends upon not only just a costly piece of technology, but also on
more expensive consumables and trained human resource. Cataract
surgery has become a refractive surgery today as patients demand
better and earlier visual rehabilitation. 
 Pachoemulsification
• Before the phacoemulsification can be performed, one or more incisions are made in the eye to allow the
introduction of surgical instruments. The surgeon then removes the anterior face of the capsule that contains the
lens inside the eye. Phacoemulsification surgery involves the use of a machine with microprocessor-controlled
fluid dynamics. These can be based on peristaltic or a venturi type of pump.
• The phaco probe is an ultrasonic handpiece with a titanium or steel needle. The tip of the needle vibrates at
ultrasonic frequency to sculpt and emulsify the cataract while the pump aspirates particles through the tip. In
some techniques, a second fine steel instrument called a "chopper" is used from a side port to help with chopping
the nucleus into smaller pieces. The cataract is usually broken into two or four pieces and each piece is emulsified
and aspirated out with suction. The nucleus emulsification makes it easier to aspirate the particles. After
removing all hard central lens nucleus with phacoemulsification, the softer outer lens cortex is removed with
suction only.
• An irrigation-aspiration probe or a bimanual system is used to aspirate out the remaining peripheral cortical
matter, while leaving the posterior capsule intact. As with other cataract extraction procedures, an intraocular
lens implant (IOL), is placed into the remaining lens capsule. For implanting a poly(methyl methacrylate) (PMMA)
IOL, the incision has to be enlarged. For implanting a foldable IOL, the incision does not have to be enlarged. The
foldable IOL, made of silicone or acrylic of appropriate power is folded either using a holder/folder, or a
proprietary insertion device provided along with the IOL.
• It is then inserted and placed in the posterior chamber in the capsular bag (in-the-bag implantation). Sometimes,
a ciliary sulcus implantation may be required because of posterior capsular tears or because of zonular dialysis.
Because a smaller incision is required, few or no stitches are needed and the patient's recovery time is usually
shorter when using a foldable IOL.
Hypothermic vs normothermic in phaco
Study Hypothermic effect of BSS

Fujishima Cooling is an important means of reducing postoperative pain and

et al (1994) inflammation
Joussen et The ionic composition of irrigating solutions is important in the outcome
al (2000) of phacoemulsification and that there is no detectable effect of the
irrigating solution temperature

Zhang et al Using cryoirrigation during the phaco procedure could alleviate

(2009) postoperative cornea edema without any apparent side effect. The
optimal hypothermia temperature for intraocular irrigation in cataract
surgery needs to be verified in future studies.
Hypothermic vs normothermic in phaco
Study Hypothermic effect of BSS
Praveen et al A 10oC decrease in the temperature of the ocular tissue can reduce the
(2009) metabolic activity of the cornea by as much as 50%. It was suggested that
cooled irrigating solutions appear to inhibit acute blood aqueous barrier
disturbance but delay and possibly prolong the inflammation when compared
with irrigating solutions at room temperature. In a study conducted on rabbit
eyes, it was observed that cooled irrigating solutions lowered fibrin
production and postoperative inflammation as compared with solutions at
room temperature. It has been hypothesized by others that the hypothermic
effect may be due to a generalized slowing down in the tissue metabolism and
enzymatic reactions as well as decreased uveal blood flow.
Salcedo- It has been demonstrated that retinas subjected to mild or moderate
Villanueva et hypothermia had a decrement in neuronal energy metabolism which is fully
al (2014) restored once the retinas were placed under normo-thermic conditions.
Hypothermia during PPV may reduce retinal damage in pressure-induced
ischemia, and under normal pressure, low temperature significantly inhibits
the break-down of blood–aqueous barrier; with more severe ischemia,
hypothermia at 8 C will protect the retina more effectively.
 Specular microscope
• The specular microscope is used to give a highly
magnified image (in excess of x100) of both the
corneal epithelium and more particularly, the
endothelium. These structures would otherwise be
difficult to observe because of their normal
transparency. Light is focused near to the focal
plane of the objective close to a point of reflection.
This gives a specular image to permit an assessment
of features such as cell density, polymegathism and
corneal thickness
 Effect of hypothermic of Lactated Ringer’s
solution vs other solutions
Study RL vs Other solutions
Joussenet al, 2000 - BSS Plus induced less short-term corneal swelling than Ringer’s
solution. From these findings, it appears that BSS Plus may decrease
corneal risk in cases with compromised corneas or prolonged surgery
- Corneal endothelial safety is the guideline for developing intraocular
irrigating solutions. Whereas balanced salt solutions are known to
promote toxic cell alterations, certain additives such as adenosine
and glutathione have positive effects on endothelial pump function.
The ATPase-dependent pump function prevents stromal hydration
because of hyperosmolarity. Dextrose is known to prevent swelling of
cultured corneal epithelial cells.

- This was the rationale behind the development of BSS Plus, which
contains oxidated glutathione and bicarbonate as well as dextrose in
a balanced ionic solution
 Effect of hypothermic of Lactated
Ringer’s solution vs other solutions
Study RL vs Other solutions
Vasavada et al, - BSS offers a significant advantage over RL in terms of increase in
2009 corneal thickness and postoperative inflammation on the first
postoperative day in patients undergoing phacoemulsification
- RL lacks several essential constituents necessary for endothelial
functioning and protection, it remains the most widely used irrigating
fluid in our part of the world due to its low cost

- RL is hypotonic and slightly acidic (osmolality 280mmol, pH 6.0) as

compared to BSS (osmolality 302 mmol, pH 7.4) and aqueous
(osmolality 302 mmol, pH 7.4). It lacks a buffer system and energy
source for the endothelium. In addition to potassium, calcium, and
lactate, BSS contains magnesium (essential for the Mg-ATPase
endothelial pump) and an acetate citrate buffer system
 Effect of hypothermic of Lactated
Ringer’s solution vs other solutions
Study RL vs Other solutions
Lucena et al, 2011 - Ringers solution was similar to BSS Plus for corneal preservation in
atraumatic cataract surgery.
- dextrose bicarbonate Lactated Ringer’s solution for irrigation hasm
been reported to be as effective as enriched BSS during cataract
surgery, and some authors consider operating time and irrigation
volume to be important clinical factors for endothelial cell loss during
phacoemulsification cataract surgery.

- In fact, BSS Plus and Lactated Ringer’s have common aqueous

humour constituents: sodium chloride, potassium chloride, calcium
chloride. However, just BSS Plus has magnesium, sodium phosphate,
sodium bicarbonate, dextrose and glutathione, which are also
present in aqueous humour
 Effect of hypothermic of Lactated
Ringer’s solution vs other solutions
Study RL vs Other solutions
Al-Sharkawy , - Ringer’s and Ringer’s lactate solutions are associated with minimal
2015 changes in corneal ECD, morphology, and function during
uncomplicated phacoemulsification with foldable intraocular lens
implantation in patients with normal endothelial cell counts. There is
no clinically significant difference in endothelial cell preservation and
polymegathism and corneal swelling between Ringer’s and Ringer’s
lactate solutions.

- Despite the fact that Ringer’s lactate lacks several essential

constituents necessary for endothelial functioning and protection, it
remains the most widely used irrigating fluid in our part of the world
due to its low cost
Corneal anatomy
Corneal anatomy
Corneal anatomy
Corneal anatomy
Corneal anatomy
Corneal anatomy
Corneal innervation
 Enhanced corneal compensation
• To improve the signal to noise ratio and yet still achieve
individualised corneal compensation, a new software based
compensation method, called enhanced corneal compensation
algorithm (ECC), has been developed.
• In ECC, a known large birefringence bias is introduced into the
measurement beam path to shift the measurement of total
retardation into a higher value region; this is in contrast to VCC
measurement where SLP directly measures the relatively low
RNFL retardation. The birefringence bias is determined from
the macular region of each measurement and then, point by
point, removed mathematically to yield the true RNFL
retardation.
Enhanced corneal compensation
Mannis MJ, Miller RB, Carlson EC, Hinds D, and May DR (1983).
Effect of hypothermic perfusion on corneal endothelial
morphology. British Journal of Ophthalmology. 67: 804-807.
 Fujishima H, Yagi Y, Toda I, Shimazaki J, Tsubota K (1994).
Increased Comfort and Decreased Inflammation of the Eye by
Cooling After Cataract Surgery. American Journal Of
Ophthalmology. 119: 301-306
 Joussen AM, Barth U, Cubuk H,
Koch HR (2000). Effect of irrigating solution and irrigation
temperature on the cornea and pupil during
phacoemulsification. J Cataract Refract Surg. 26: 392-397.
 Praveen MR, Vasavada AR, Shah R and
Vasavada VA (2009). Effect of room temperature and cooled
intraocular irrigating solution on the cornea and anterior
segment inflammation after phacoemulsification: a randomized
clinical trial. Eye. 23: 1158–1163.
 Zhang S, Wang J, Liu J (2009). Cryoirrigation in
phacoemulsification facilitates a quicker cornea endothelia
recovery. Can J Ophthalmol. 44(4): 446-450.