When it comes to viscoelastics, surgical facility managers face a special challenge in the quest to keep surgical volume high and costs low. Two of the three viscoelastics surgeons prefer most may cost 50 to 150 percent more than most competitive products (see "Street Prices at a Glance" on page 62).

If your surgeons are unyielding about their preferences and offering them pricier products is the difference between their operating at your facility or taking their cases elsewhere, the extra $40 to $80 per case is probably worth it. But if your surgeons are pliable, it may be reasonable to propose trials of less popular but more economical products. If you find acceptable alternatives, you may at the very least strengthen your negotiating position to obtain the more expensive products at a more favorable price. With that in mind, here's a look at the market.

DuoVisc, Viscoat and ProVisc
By far the most popular viscoelastic is Alcon's DuoVisc (Fig. 1). It packages the dispersive or short-chain Viscoat and the cohesive or long-chain ProVisc together. Many surgeons use Viscoat for the first half of the procedure, since it adheres to the corneal endothelium and resists being sucked out of the eye all at once during phacoemulsification. They use ProVisc for the second half, because its thickness provides better dynamics for IOL placement and because long-chain viscoelastics are easier to remove at a procedure's end. Leftover viscoelastic can block egress of the aqueous and cause glaucomatous pressure spikes.

"Viscoat does a good job of coating the endothelium and is very retentive," says John D. Dugan Jr., MD, of the Wills Eye Hospital in Philadelphia. "ProVisc is easier to get out at the end of a case, so you can use the soft shell technique where you fill the eye with the Viscoat and then fill the eye with the ProVisc."

According to the 2002 American Society of Cataract and Refractive Surgeons survey, 33.9 percent of surgeons who responded usually use DuoVisc. According to Alcon Marketing Manager of Viscosurgical Devices Joe VonderHaar, the product owns about 56 percent of the total market.

The downside is that DuoVisc sells for between $75 and $85 on the street, according to our informal survey of five facility managers. The price is reasonable considering the product incorporates two vials of visco-elastic, but as a single product, DuoVisc still costs more than most competitive products.

Interestingly, Viscoat is the next most popular product among surgeons according to the ASCRS survey; 15.5 percent of surgeons most commonly use it alone for their cases. A little more than 7 percent most often use ProVisc. Either product used alone costs around $40, in line with other products.

For economy-minded facilities, Alcon also offers low-viscosity Cellugel.

Amvisc Plus, Amvisc and Ocucoat
Bausch & Lomb's Amvisc Plus is technically a cohesive, but the molecule size is smaller than most cohesives, which surgeons say results in a unique feel (Fig. 2). This is the third-most popular viscoelastic, according to the ASCRS survey, with 8.5 percent of surgeons saying it's the viscoelastic they use most often.

"It walks that line between cohesive and dispersive," says Andrew Tharp, MD, of the Wellborn Clinic East in Evansville, Ind. "By going to medium-size [molecules] ... it still has cohesive properties and will stay in the eye." He says Amvisc Plus has a bit more "springiness" than Viscoat.

He likes the idea of a viscoelastic that has properties of both a cohesive and a dispersive; he thinks it's more convenient than using two separate products. "It's easily equally effective (as DuoVisc)," says Dr. Tharp. "It doesn't have the downside that you have to go in and out of the eye so much."

Dr. Tharp calls it his "workhorse viscoelastic," and endorses it "for routine cases when I want them to stay routine."

The negative for Amvisc Plus is cost: At a "street price" of well over $100, it's the most expensive product on the market. For the more cost-conscious, B&L offers Amvisc and Ocucoat. Both are under $30.

Amvisc, also one of the most popular non-Alcon viscoelastics, is a cohesive viscoelastic touted by the company as "excellent for chamber maintenance," with "complete removal at the end of the case ' quickly and easily accomplished."

Ocucoat is a low-viscosity, dispersive product that, B&L says, is best for surgeons who do high-volume, small-incision cataract surgery. Ocucoat is clear, has a low molecular weight, and, B&L says, provides outstanding lubrication, which facilitates IOL implantation with an insertion device.

Healon, Healon GV and Healon 5
According to Pharmacia, Healon 5 is a "viscoadaptive," in that it acts as a cohesive and a dispersive, adapting throughout surgery (Fig. 3). It's latex free, and is moderately priced.

"I found that Healon 5 stays in the eye when you manipulate the wound," says Dr. Dugan. "Others have a tendency to burp out. [Healon 5] offers advantages in cases where you need more space ' in situations where you're going to be stretching the pupil. And because it stays in the eye, you tend to use a little less."

The knock on Healon 5 is its thickness; Robert Osher, MD, the medical director emeritus of the Cincinnati Eye Institute in Montgomery, Ohio, recommends keeping aspiration and vacuum low to adjust for this property. To remove the product, simply turn up the two parameters, and Healon 5 can be "easily, completely, quickly and safely removed."

Dr. Osher, a professor of ophthalmology at the University of Cincinnati, recently studied the efficacy of Healon 5 in 100 consecutive cataract procedures. He says the results show the cornea stays clear after surgery and that 96 percent of patients achieve an uncorrected visual of 20/40 or better the day after surgery.

Pharmacia also offers Healon and Healon GV, two of the top five non-Alcon viscoelastics.

Healon is a cohesive comprised of long molecular chains that, the company says, at rest, create space and absorb shock. However, at high shear rates, Healon becomes very fluid, facilitating injection of the IOL. Healon is much less viscous than Healon GV, a high-molecular-weight cohesive. Pharmacia recommends Healon GV for foldable IOL surgery and touts is clarity, space creation, control and endothelial protection.

CoEase and Univisc
For surgeons who feel simple is better, AMO's CoEase and Ciba Vision's Univisc are two options.

"We don't need as sophisticated viscoelastic solutions as we did in the past ... we're putting less energy into the eye and just don't need as much protection," says John Hunkeler, MD, of the Hunkeler Eye Centers in Kansas City, Mo. "So we have the alternative of going back to viscoelastics that ... [provide] space to do capsulorhexis."

For this reason, Dr. Hunkeler uses CoEase (Fig. 4) for most cases. CoEase is a cohesive viscoelastic for use in the anterior and posterior chambers that is meant to maintain anterior chamber depth and visibility, and of course, to protect corneal endothelium.

"It does what you want it to do, then you can get it out of the eye," says Dr. Hunkeler. "You get clear corneas ... and [with CoEase] you reduce the likelihood of unwanted elevation of intraocular pressure."

Ciba markets Univisc (Fig. 5), a cohesive, high-viscosity product; Robert Block, MD, of the Santa Cruz Medical Foundation in Santa Cruz, Calif., feels it has dispersive qualities, too, and that it's the most cost-effective viscoelastic he's used. "It's tre-mendously versatile," he says. "I think it's the best for clarity."

He's had good short-term post-op results for patients since he started using Univisc.

"There's very little corneal edema after surgeries," Dr. Block says. "The only ones I'm getting bad edema on are the 3-plus to 4-plus nuclei. By and large, my corneas have really great clarity the next day."

Dr. Block uses Univisc for most cases, but notes it may not be the best product for tamponading vitreous if you tear the posterior capsule.