This should come as no surprise to you: In nearly every place I've worked, physician preference has overwhelmingly dictated which brand and type of viscoelastic the facility buys. Often, it's a matter of what surgeons used when they learned to perform cataract procedures. But that doesn't mean you have to carry a different viscoelastic for every surgeon who operates at your facility; standardization of product is necessary to remain cost-effective and efficient.

Chill out
First of all, carrying a significant inventory of viscoelastics can provide a real storage problem. Most facilities don't have the refrigerated storage capacity to maintain par levels for a half-dozen types of viscoelastic. It's not just an issue for multi-specialty facilities, but also for single-specialty ophthalmic centers, as many are small, with maybe one or two ORs, and the storage areas are correspondingly small. Viscoelastic ends up being stored in the medication refrigerator in pre- or post-op, and someone has to run to get it when setting up rooms.

I've never seen viscoelastic hit its expiration date; it's something you use every case, so it rotates stock very quickly. But I have seen thousands of dollars wasted on product left unrefrigerated in the Arizona heat. Left for more than four hours at room temperature, the product loses viscosity. Adding refrigerated storage space not only cuts the time you spend ordering but potentially the cost of the viscoelastic - you could buy it in bigger lots - and shipping, which really adds up over time.

Another way to ameliorate this issue is to switch away from refrigerated viscoelastic altogether or even partially. I know facilities that have trouble finding space, so they stock a minimal amount of their physician-preferred visco, and the back-up stock is always Ocucoat, which doesn't have to be refrigerated. For this very reason, Ocucoat is the viscoelastic of choice on medical missions.

One-two punch
The biggest concerns are whether the viscoelastic you choose will effectively accomplish the task and yet be easily removed. For this reason, during the capsulorhexis, depending on technique, some surgeons might want to use a more fluid dispersive (a methylcellulose, such as Ocucoat), then switch to a thicker cohesive (a sodium hyaluronidase, such as Healon or Shellgel) for lens implantation. (See the product round-up for descriptions of each kind of viscoelastic.)

If that's the case, you have two basic options. One is to bring syringes of both types into the OR for every case; the other is to use Alcon's DuoVisc, which pre-packages Viscoat 3.5 and Provisc in one box. Unfortunately, they aren't packaged individually so that you can maintain the sterility of one. But in my experience, even if your surgeon doesn't end up using one or the other, because each syringe contains a smaller volume, you're not wasting as much as you would using separately packaged viscoelastics.

Manufacturers say the so-called viscous dispersives or dispersive cohesives - such as Staarvisc and Amvisc - can be used throughout a procedure, but these viscoelastics are generally more cohesive than anything else and, for surgeons who insist on using two products, are used during lens implantation. Then there's DisCoVisc 1.0ml, which is brand new to the market and is a unique combination of sodium hyaluronate and chondroitin sulfate. It's said to be optimized for use throughout the procedure: very clear and acting like a cohesive, yet easily removable like a dispersive.

New surgeons almost always want to use cohesives, and many doctors just prefer it forever - but you will pay more for the cohesives. It's often worth it to make the effort to get them to switch to dispersives. I find that, especially if they are part-owners in the center, physicians are willing try products that will save them money. The less expensive Ocucoat, for example, comes in a 1ml size, whereas others come in .5ml or less, so they can feel free to use larger volumes of the visco to compensate for the smaller molecular-chain size.

Don't make things so complicated
Before you go standardizing entirely, there are two potential complications or complex cases that might require specific types of viscoelastic.

• Weak zonules. When you have poor zonular support, the first line of action is to use a thick, cohesive viscoelastic to hold the bag open. It's a lot less expensive than using a capsular tension ring, that's for sure.
• Pseudoexfoliation. This is a defect of the lens capsule that makes patients more prone to glaucoma, so you may see it in your ECP patients. Because the lens capsule is very fragile, there is a higher risk of posterior capsular rupture - and the aforementioned zonular weakness. Again, a cohesive is your best bet.

Also, if you're doing ECP along with cataract extraction, you're supposed to use cohesive visco, as the ECP manufacturer says it's the only one that facilitates the laser beam and lets you treat the eye.

Bundle up
If your surgeons are willing to use IOLs, tubing and viscoelastic, among other things, made by just one company, that loyalty can literally pay off. Sometimes supply prices are tied to capital equipment, such as a phaco machine, but it's overwhelmingly tied to the specialty supplies that you order - and the volume.

In my experience, bundling will save you significant money. Manufacturers all do it differently. Some simply give you a decrease in pricing, but others will give you a rebate based on usage and compliance.

One note of advice: If you do bundle, insist that the company you deal with be able to give you their unbundled pricing, as Medicare regulations require that you be able to itemize your lens cost.

Amvisc Plus
Bausch & Lomb Surgical
(800) 338-2020
www.bausch.com
List price: not disclosed
FYI: One-vial Amvisc Plus features moderate cohesiveness and dispersive properties, says the company. Made of 1.6% sodium hyaluronate, the product is indicated for use as a surgical aid in ophthalmic anterior- and posterior-segment surgery. Amvisc Plus is available in both 0.5ml and 0.8ml sizes.

DisCoVisc
Alcon Laboratories
(800) 757-9195
www.alconlabs.com
List price: $175
FYI: Alcon bills its DisCoVisc as the first viscoelastic optimized for the entire surgical procedure. Delivered in a 1ml, latex-free syringe, it's a viscous dispersive containing 1.7% sodium hyaluronate and 4% chondroitin sulfate for use during anterior-segment surgery.

DuoVisc
Alcon Laboratories
(800) 757-9195
www.alconlabs.com
List price: $157.68
FYI: By combining cohesive and dispersive viscoelastic, DuoVisc offers corneal andothelium during phacoemulsification with an ease of removal after IOL implantation, says Alcon. Available in large and small volumes, DuoVisc consists of two products: Viscoat (the 3% sodium hyaluronate and 4% chondroitin sulfate dispersive) and ProVisc (the 1% sodium hyaluronate cohesive).

Healon
Advanced Medical Optics
(714) 247-8200
www.amo-inc.com
List price: not disclosed
FYI: Healon, a 1% sodium hyaluronate latex-free cohesive, is indicated for use in anterior- and posterior-segment surgery. A clear field is created, says AMO, allowing facilitation of intra- and post-operative inspection of the retina and photocoagulation.

Healon5
Advanced Medical Optics
(714) 247-8200
www.amo-inc.com
List price: not disclosed
FYI: Healon5 is described by AMO as a latex-free 2.3% sodium hyaluronate viscoadaptive for procedures in the anterior segment, including both routine and complex cataract procedures. Of the Healon family products, Healon5 offers the highest resting state viscosity, AMO says.

Healon GV
Advanced Medical Optics
(714) 247-8200
www.amo-inc.com
List price: not disclosed
FYI: The cohesive, latex-free Healon GV, made of 1.4 % sodium hyaluronate and latex free, is billed by AMO as having the highest molecular weight of any viscoelastic. Further, the company says the product expands once in the anterior chamber and that the molecular chains easily realign for efficient removal during high flow.

Ocucoat
Bausch & Lomb Surgical
(800) 338-2020
www.bausch.com
List price: not disclosed
FYI: Ocucoat, a 2% hydroxypropyl methylcellulose dispersive, features a low molecular weight, which allows for rapid removal with minimal risk of increased intraocular pressure that makes it optimum for use in phakic lens implantations, says Bausch & Lomb. Available in 1ml vials, it's indicated for use in anterior-segment procedures.

Shellgel
Cytosol Ophthalmics
(800) 234-5166
www.cytosol.com
List price: not disclosed
FYI: A latex-free, sodium hyaluronate viscoelastic, Shellgel is designed to be used in both the anterior and posterior segments for procedures including cataract extraction, corneal transplantation, retina reattachment, IOL implantation and glaucoma filtering. It is packaged in a 0.8ml syringe.

Staarvisc II
Staar Surgical
(800) 352-7842
www.staar.com
List Price: not disclosed
FYI: A dispersive cohesive viscoelastic, Staarvisc II allows clarity that permits an unobstructed view of the surgical field throughout capsulorhexis and phacoemulsification. Consisting of 1.2% sodium hyaluronate and available in a 0.8ml syringe, Staar says its product has viscosity that allows for excellent anterior chamber maintenance and complete removal at the end of the case, "easily and quickly." It's priced to compete with any sodium hyaluronate viscoelastic agents, says the company.

The long-hair answer
Tuck away that long hair in style, thanks to a new scrub hat by Blue Sky Scrubs.

For those looking for a change from the elasticized bouffant surgical caps, Shelby Marquardt, MD, an anesthesiology resident, created the patent-pending Pony scrub. It functions exactly as the traditional slim-fitting scrub cap does, with the one difference being a special cinched-pouch in the back designed to accommodate both long and short ponytails, says the company. It's available in 39 colors and patterns.

To wear the cap, cinch the pocket in the rear before placing the ponytail inside, then pull two ribbons and close the compartment.

The company is also working on the completion of a disposable version of the Pony scrub. It is expected to be available to healthcare facilities this month.

Pony scrubs list for $24 each. Cost for a box of 100 disposable Pony scrubs will run between $20 and $40. Complimentary samples are available. For more information, call (877) 932-6754, visit www.blueskyscrubs.com or circle number 167 on your Reader Service Card.

Longer length, non-stick, disposable electrode comes in four tips
For bariatric procedures where additional length is needed, such as gastric bypass and gastric banding, Megadyne launched what it bills as the first 45cm disposable laparoscopic electrode with a patented PTFE-coated electrosurgical tip.

The 45cm electrodes come in four tip configurations - curved, L-hook, J-hook and L-wire - and have the company's patented E-Z Clean, a green non-stick coating. The E-Z Clean tips minimize eschar buildup and are used with a lower power setting, which reduces excess smoke and thermal necrosis, Megadyne says.

The 45cm disposable electrode with E-Z Clean lists for $58. For more information, call (800) 747-6110, visit www.megadyne.com or circle number 168 on your Reader Service Card.

Breathe better with an integrated isolation room ventilation system
For your immunocompromised patients, Precision Air Products offers the Life-Island Systems, an integrated isolation room ventilation system. Providing HEPA-filtered laminar airflow, the system protects patients, visitors and healthcare workers from airborne microorganisms.

The filter is 99.9 percent efficient at removing bacteria carrying particles (0.3 microns or larger), the company says. The air flows over the patient, partially pressurizing the area immediately surrounding the bed. The system then draws this air away from the patient, either returning it to be re-filtered or exhausting it out of the room and building. It's available for horizontal or vertical airflow and between corridor, end or low return. The system is self-contained and does not require increasing the size of the air handler serving the isolation room.

The Life-Island System is also integrated with other typical isolation room amenities, the company says. The headwall contains utilities for med gases, power, communication and lighting. Optional swing walls provide an extra barrier between the patient and healthcare workers or visitors and swings out of the way for room cleaning.

Precision Air Products offers customized unidirectional flow isolation room solutions starting at $5,000. For more information, call (800) 404-0931, visit www.precisionairproducts.com or circle number 169 on your Reader Service Card.

Label packs before sterilization while inventorying just one label
Universal Load Record Labels by SPSmedical can be used in steam, EtO gas and peracetic acid sterilizers. The latex-free product is available in a variety of styles and fits the most popular label applicators.

The Load Record Labels list for $81 for a box of 12 rolls. Complimentary sample rolls are available. For more information, call (800) 722-1529, visit www.spsmedical.com or circle number 171 on your Reader Service Card.

Scrub sinks that are easy to install and maintain
For easy installation and maintenance, Just Manufacturing offers its Enviro 770 Series of pre-piped, stainless steel scrub sinks.

Available as complete packaged one-, two-, or three-station units, the surgeon scrub sinks combine sensor faucets, thermostatic mixing valves, p-trap and drain systems as well as removable Plexiglas partitions on multi-station units. Each system also features removable front access panels for installation and maintenance, says the company. The integral 12-gauge brackets allow increased stability, it adds.

Sensor faucets are offered in AC or DC models with a manual mixing override or user adjustment capability. It meets requirements for medical installation. The product has a fully blended satin finish, fully undercoated bottom and is available with a stainless steel shelf, which runs the width of the sink.

The Enviro 770 Series Scrub Sink lists for $6,190. For more information, call (847) 678-5150, visit www.justmfg.com or circle number 170 on your Reader Service Card.

Wristbands with short-stay patients in mind
Designed particularly for short-stay patients, Precision Dynamics Corporation introduces Securline Short Stay LabelBand featuring a clear adhesive shield and tough construction. If you're looking to implement wristbands that provide results instantly, the Short Stay LabelBand offers bar code scanning and protection from water, solvents and other abrasives, says the company.

The Tyvek construction makes the wristbands durable, yet non-abrasive to sensitive skin; the non-transferable adhesive closure has a clear shield with tamper-evident slits for added patient safety and security. A large label area accommodates both laser and thermal labels.

Short Stay LabelBand is a new addition to the company's barcode hospital band product line, Sentry Bar Code LabelBand, PDC adds.

The bands list at 15 cents each. For more information, call (800) 772-1122, visit www.pdcorp.com or circle number 172 on your Reader Service Card.

The latest LCD technology hits the OR
To provide superior image accuracy and meet the unique patient safety and space requirements of a digital, integrated OR, Barco developed its MDSC-1119 surgical display, the company says. The 19-inch screen has a 1.3 megapixel color LCD display and features high brightness, contrast ratio and color depth, and a wide viewing angle to make it ideal for the OR's low-light conditions, says Barco.

It also offers the fastest image transmission and broadcast quality video imaging available, the company adds, with great attention paid to signal integrity. The MDSC-1119 is enhanced with Barco's image processing algorithms, such as Response Time Improvement System and motion adaptive de-interlacing to offer surgeons artifact- and lag-free images at all times. The product is a versatile multi-modality display for endoscopic cameras, room and boom cameras, ultrasound, cardiology, PACS, anesthesiology and patient information. Dual channel picture-in-picture or picture-by-picture views are available.

Barco has not yet set pricing on the MDSC-1119 surgical display. For more information, call (678) 475-8000, visit www.barco.com or circle number 174 on your Reader Service Card.

Prepare your staff for an MH episode
An in-service kit, prepared by the Malignant Hyperthermia Association of the United States, is now available to prepare your OR and PACU staff for a malignant hyperthermia episode. The kit includes a 26-minute video (on DVD or VHS), a mock drill, new information on dantrolene mixing and patient safety, and the latest information on the molecular genetic basis for the disorder. (MH is an inherited metabolic disorder of muscle, triggered by certain general anesthetics.) An informational booklet and quiz, featuring a version for CEU nurses and one for CME physicians, is also included.

The kit costs $75 plus shipping and handling; MHAUS is offering a promotion to receive the kit for free if you purchase or renew a membership and buy a procedure manual together. A new or renewed membership alone costs $35. Combined with the procedure manual, the cost is $222.50. For more information, call (607) 674-7901, visit www.mhaus.org or circle number 173 on your Reader Service Card.