In a recent conversation, Dr Shultz discussed two newly available OVDs—StableVisc, a cohesive viscoelastic, and TotalVisc, a dual-pack containing both 1 mL of StableVisc and 1 mL of ClearVisc™, a dispersive viscoelastic, previously released by B+L in 2021.1,2

Experience With StableVisc and ClearVisc

“I was fortunate to be a participant in the StableVisc clinical trials, the results of which were published this year. I instantly recognized StableVisc as an important advancement in viscoelastic devices. In the clinical trials, we used it for the entire surgery—providing chamber maintenance, performing capsulotomies, doing phaco, and placing lenses in patients with grade I-III cataracts.3 We found that it was easy to control the capsulotomy with StableVisc.”3

“I was not part of the clinical trials of ClearVisc, the other component in TotalVisc, but I have had the good fortune of being one of the longest users of the device. I use ClearVisc routinely now for all my cases, and specifically for cases where there is a need for extensive endothelial cell protection, such as the denser cases that we see. In my area, we have a lot of patients with pseudoexfoliation who wait a long time for cataract surgery. These are extremely dense cataracts that could benefit from an extra level of protection.”4,5

“Certainly, there are multiple factors that can cause corneal edema after surgery. But we want to minimize the trauma from the phacoemulsification itself and from fragments of the lens that might bounce up against the cornea if it’s not protected. We know that the cornea is protected with ClearVisc because on occasion we see small fragments of the lens that become embedded in the ClearVisc. We have to remove it with a vacuum; ClearVisc offers the protection that we need as surgeons.”

“ClearVisc also controls the anterior capsule well.a This is especially important in patients with white cataracts to reduce the risk of Argentinian flags, and when performing manual capsulotomies so that you reduce the risk of a capsule tearing out on you.”

“A nice thing with ClearVisc is its large vial—1 mL.6 When we fill the anterior chamber prior to removal of the lens, it holds only 0.2 to 0.3 mL of viscoelastic. This enables me to use the device to coat the cornea as well, so I don’t have to rely on my technicians to drop BSS (balance salt solution) during the case. The product helps to protect and maintain a clear cornea.”


“StableVisc is crystal clear. When we’re filling the anterior chamber, it has this brilliance to it. It’s difficult to describe this clarity. You have terrific visualization of the posterior capsule, and also for polishing purposes. Also, as we’re filling the entire chamber, it’s important to try to remove all of the dispersive viscoelastic at the beginning of the case and to direct or push the remaining dispersive viscoelastic out of the center. This is really important, especially when performing intraoperative aberrometry measurements. You don’t want to have a mix of those two viscoelastics. Sometimes when we introduce StableVisc, we can actually see the separation between the two OVDs.”

“StableVisc is crystal clear. When we're filling the anterior chamber, it has this brilliance to it.”

- Dr Mitchell C. Shultz
TotalVisc Packaging Group

“With ClearVisc, I typically place a couple of drops of irrigating solution on the cornea, which helps facilitate the coalescence of the device for surgery. ClearVisc provides optimal visualization during surgery.7,a It stays clear and it stays where I put it. After phacoemulsification, I remove it.”

Critical Timesaving Properties

“One of the advantages of TotalVisc is the volume of the product. You don’t have to worry about opening up additional viscoelastic, which is not uncommon with other OVDs. That’s really crucial. With other OVDs, the fill size is much smaller, and in larger eyes, once you’ve removed the lens, you then have to fill both the anterior chamber as well as the lens bag complex. This can be an issue when performing intraoperative aberrometry in these eyes. Both the fill volume of TotalVisc and the ability to remove it quickly save you time, which is a major factor that surgeons look for.”3,7

“In the wet lab survey, surgeons commented that StableVisc was rated 'excellent' for ease of removal and that’s one of the attributes where it performed slightly better.7 I have found that my results are similar to the wet lab.”b

bcompared to VisCoat®.

Safety Profiles

“Overall, the safety profiles of ClearVisc and StableVisc are excellent. The issue with any dispersive viscoelastic is that if you don’t remove it, you run the risk of having IOP spikes. You have to spend a little bit of time making sure that you’ve removed the viscoelastic from the periphery because if you don’t, that will likely cause an IOP spike. In the FDA clinical studies for StableVisc and ClearVisc, the components of TotalVisc, StableVisc was significantly noninferior to ProVisc® in the proportion of patients with postoperative IOP ≥ 30 mm Hg at any follow-up visit—5.2% for StableVisc and 8.2% for ProVisc.3,7 ClearVisc was significantly noninferior to Viscoat in the proportion of patients with postoperative IOP ≥30 mm Hg at any follow-up visit (17.4% and 20.3%, respectively, P = .0002).”7

“It’s important to remember that when postoperative IOP spikes do occur during cataract surgery, to look at other factors to determine the cause. They can be due to an independent pathology, such as inflammation like trabeculitis.”

Delivering Free Radical Protection You Can Count On

“During phacoemulsification, the ultrasonic device creates microbubbles that can cause the formation of free radicals in the anterior chamber. Free radicals can form from the heat and changes to the aqueous, as well as the microfragments from the lens particles that might be dispersed during the surgery.”7

“Free radicals create oxidative stress that damages tissues and is partially responsible for postoperative endothelial cell loss, as well as causing corneal edema at the end of surgery.8 One of the unique properties of TotalVisc is that both components include the active ingredient sorbitol, which has the ability to control free radical formation due to adding an extra layer of chemical protection to the already excellent mechanical protection.1,8,9 By helping to reduce or sequester the free radicals, we help to improve the chance that we’re going to have a clear cornea postoperatively.”8

“I believe that the ability to sequester the free radicals in the anterior chamber is an important reason why TotalVisc achieves a low risk of postoperative corneal edema.”3,7