Systems and methods for visualizing ophthalmic viscosurgical device during and following ocular surgery and viscosurgery

Abstract

A kit for ocular surgery includes a syringe comprising a needle having dimensions suitable for injecting an ophthalmic viscosurgical device OVD material to form an OVD in an eye for ocular surgery; a suitable amount of OVD material for forming the OVD loaded into the syringe; and instructions for suitable optical illumination to be used to observe the OVD, or a remaining portion thereof, at least one of during or after the ocular surgery based on a response of the OVD material to the optical illumination. The OVD material includes a polymer and at least one of a dye, a fluorophore, a luminophore, or a quantum dot conjugated to the polymer.

Description

SYSTEMS AND METHODS FOR VISUALIZING OPHTHALMIC VISCOSURGICAL DEVICE DURING AND FOLLOWING OCULAR SURGERY AND VISCOSURGERYCROSS-REFERENCE TO RELATED APPLICATIONS

[0001] The present patent application claims priority benefit to U.S. Provisional Patent Application No. 63 / 564,602, filed on March 13, 2024, the entire content of which is incorporated herein by reference. All references cited anywhere in this specification, including the Background and Detailed Description sections, are incorporated by reference as if each had been individually incorporated.BACKGROUND1. Technical Field

[0002] The currently claimed embodiments of the present invention relate to materials, systems and methods for the use of ophthalmic viscosurgical devices (OVDs) during and following ocular surgery and viscosurgery.2. Discussion of Related Art

[0003] Ophthalmic Viscosurgical Devices (aka Ophthalmic Viscoelastic Devices), herein referred to as ‘‘OVD”, revolutionized ophthalmic surgery since their first description in 1972. OVDs are viscoelastic hydrogels injected into the eye during ocular surgery’. These hydrogels are enabled by hydrophilic polymers, often sodium hyaluronate, chondroitin sulfate, hydroxypropyl methylcellulose, or combinations thereof. The properties and uses of OVDs are highly dependent on the molecular weight and concentration of these polymers, and thus their viscoelastic properties.

[0004] OVDs are vitally important tools in several types of ocular surgery, in particular for anterior segment surgeries such as cataract surgery'. In these operations, OVD maintains pressure within the anterior chamber, allows for intraoperative compartmentalization of the eye, andprovides needed protection of the corneal endothelium, in particular during phacoemulsification, wherein ultrasonic energy is used to dissolve the clouded native lens in cataract surgery'.

[0005] While OVDs are a vital tool to modem anterior segment eye surgery, they must be thoroughly removed from the eye prior to the completion of surgery. Large quantities of retained OVD have demonstrated significantly harmful effects on post-operative outcomes.1,2Failure to remove OVD leads to a hampered ability for the eye to drain ocular fluid through the trabecular meshwork. As a consequence, intraocular pressure (IOP) may spike to unhealthy levels in the days and hours following cataract surgery if OVD is not thoroughly removed.3This leads to discomfort and potentially severe side effects for patients. In some cases, reoperation is required to remove residual OVD.

[0006] Despite the w ell-established literature that thorough removal of OVD is necessary for optimal outcomes from ocular surgery, removal of OVD is difficult for surgeons. To remove OVD, surgeons utilize a combination of simultaneous saline irrigation and vacuum aspiration via a irrigation / aspiration (I / A) probe, a task that is particularly challenging for trainees,4,5and young / inexperienced surgeons. How ever, a lack of meticulousness in OVD removal may lead to the complications discussed prior, namely IOP spikes.

[0007] A key cause for the challenge of complete OVD removal is the difficulty' of OVD visualization during surgery. OVD is a clear hydrogel injected into a clear ocular chamber. Thus, the only way to visualize current OVDs is to examine faint “boundaries” and “borders” between OVD and aqueous humor (the natural fluid within the eye). These boundaries are often described as faint “wisps” within the eye, or as boundaries between two liquids that do not mix. Unfortunately, OVDs cannot be opaque, as it is necessary for OVD to be clear for the majority of the operation, namely during phacoemulsification and intraocular lens insertion, to enable visualization of ocular structures. This clarity7poses a challenge when OVD must be removed at the completion of a case. However, conditional visualization of OVD provides an invaluable opportunity' for surgeons to understand the degree of OVD retention intraoperatively to inform whether additional I / A is required to remove said OVD. Additionally, the conditional visualization could be utilized post-operatively to determine levels of intraocular OVD retention following a case.

[0008] Some methods to improve visualization during ocular surgery' have been explored. A US Patent Application, “VISCO DYE” (Appl. No.: 10 / 496,153, filed 2002.11.20) used OVD specifically to stain ocular structures within the eye. In particular, the capsule is stained prior to a Continuous Curvilinear Capsulorhexis. Another US Patent Application, “VITAL STAIN VISUALIZATION IN OPHTHALMIC SURGICAL PROCEDURES AND ASSOCIATED DEVICES. SYSTEMS, AND METHODS” (Appl. No.: 14 / 446,586, filed 2014.07.30). described optical methods to visualize these dyes during surgery. A European Patent Application, “Coloured visco-elastic composition” (Appl. No.: 00200811.8, filed 2000.07.03), used a vital dye to stain and visualize OVD in ocular surgery'. Namely, this patent claimed the use of trypan blue and other small molecule dyes. However, the OVD is permanently stained using this method. Therefore, there remains a need for improved materials, systems and / or methods for OVDs.SUMMARY

[0009] An embodiment of the current invention is directed to a kit for ocular surgery that includes a syringe comprising a needle having dimensions suitable for injecting an ophthalmic viscosurgical device OVD material to form an OVD in an eye for ocular surgery; a suitable amount of OVD material for forming the OVD loaded into the syringe; and instructions for suitable optical illumination to be used to observe the OVD, or a remaining portion thereof, at least one of during or after the ocular surgery based on a response of the OVD material to the optical illumination. The OVD material includes a polymer and at least one of a dye, a fluorophore, a luminophore, or a quantum dot conjugated to the polymer by at least one of covalent polymerization, copolymerization, covalent modification, conjugate addition, Michael addition, azide-alkyne cycloaddition, mechanoradical coupling, click chemistry’, streptavidin-biotin binding, ionic binding, or a combination thereof such that the at least one of a dye, a fluorophore, a luminophore, or a quantum dot remains attached within the OVD during or after the ocular surgery. The OVD material is substantially free of any of the dye, fluorophore, luminophore, or quantum dot unconjugated to the polymer.

[0010] Another embodiment of the current invention is directed to an OVD material for injecting into an eye to form an OVD for ocular surgery' that includes a polymer and at least oneof a dye, a fluorophore, a luminophore, or a quantum dot conjugated to the polymer by at least one of covalent polymerization, co-polymerization, covalent modification, conjugate addition, Michael addition, azide-alkyne cycloaddition, mechanoradical coupling, click chemistry, streptavidin-biotin binding, ionic binding, or a combination thereof such that the at least one of a dye, fluorophore, luminophore, or a quantum dot remains attached within the OVD during or after the ocular surgery. The polymer includes at least one of sodium hyaluronate, hyaluronic acid, chondroitin sulfate, hydroxypropyl methylcellulose polymer or a combination thereof, and the OVD material is substantially free of any of the dye, fluorophore, luminophore, or quantum dot unconjugated to the polymer.

[0011] A method of imaging an OVD or a remaining portion of an OVD in a patient’s eye according to an embodiment of the current invention includes illuminating the patient’s eye with light having a wavelength suitable to effect light emission from the OVD or the remaining portion thereof; and imaging the light emitted from the OVD or the remaining portion thereof. The OVD includes a polymer, and at least one of a dye, a fluorophore, a luminophore, or a quantum dot conjugated to the polymer by at least one of covalent polymerization, co-polymerization, covalent modification, conjugate addition, Michael addition, azide-alkyne cycloaddition, mechanoradical coupling, click chemistry, streptavidin-biotin binding, ionic binding, or a combination thereof such that the at least one of the dye, fluorophore, luminophore, or quantum dot remains attached within the OVD during or after the ocular surgery. The polymer includes at least one of sodium hyaluronate, hyaluronic acid, chondroitin sulfate, hydroxypropyl methylcellulose polymer or a combination thereof, and the OVD is substantially free of any of the dye, fluorophore, luminophore, or quantum dot unconj ugated to the polymer.BRIEF DESCRIPTION OF THE DRAWINGS

[0012] Embodiments of the present invention, as well as the methods of operation and functions of the related elements of structure and the combination of parts and economies of manufacture, will become more apparent upon consideration of the following description and the appended claims with reference to the accompanying drawings, all of which form a part of this specification, wherein like reference numerals designate corresponding parts in the variousfigures. It is to be expressly understood, however, that the drawings are for the purpose of illustration and description only and are not intended as a definition of the limits of the invention.

[0013] FIGS. 1A-1E are schematic illustrations to show several embodiments of method of imaging OVDs according to the current invention.

[0014] FIG. 2A-2C provide an overview in which (A) Conventional OVD uses unconjugated hydrophilic polymers, such as hyaluronic acid, to form a clear viscoelastic hydrogel (unconjOVD), used here as a negative control; (B) Prior work has admixed free fluorescein sodium into OVD (mixOVD) to allow visualization, used here as a positive control; and (C) In this study, conjugated OVD (conjOVD) is designed using a ratio of hyaluronic acid and hyaluronic acid covalently conjugated to fluorescein. This ratio is optimized to allow visualization of OVD under cobalt blue light via green fluorescence, while maintaining clarity with only a slight yellow hue under white light. OVD = ophthalmic viscosurgical device.

[0015] FIGS. 3A-3C show- in vitro assessment of conjOVD fluorescence. (A) Representative images are shown in a well plate with black background illuminated by CBL. (B) Semi- quantitative assessment of green intensity as visualized under CBL (mean ± SEM, N = 4). Significance assessed via one-way ANOVA with correction for multiple comparisons by two- stage step-up. All comparisons are significant (P < 0.05) except those noted. (C) A slight yellow' hue appears under white light with increased % conjHA, however, clarity is maintained. Printed letters can still be visualized through conjOVD under CBL despite striking fluorescence. CBL = cobalt blue light; OVD = ophthalmic viscosurgical device; conjOVD = OVD made with fluorescein-conjugated hyaluronic acid (conjHA); mixOVD = 0% conjOVD stained with 5 pg / mL fluorescein sodium; ns = not significant.

[0016] FIGS. 4A-4B show fluorescein conjugation does not significantly affect the viscosity of conjOVD. (A) Shear-ramp curves for 0% conjOVD and 10% conjOVD show characteristic shape of commercially-available OVDs, with no significant difference in viscosity at any of the shear rates tested (two-way ANOVA with Bonferroni multiple comparisons test). (B) Viscosity at a shear rate of 1 sec'1(significance assessed via t test). Viscosity assessed via rotational rheometer at 25°C. Shown are mean ± SEM (N = 3). Significance assessed as P < 0.05. OVD =ophthalmic viscosurgical device; conjOVD = OVD made with fluorescein-conjugated hyaluronic acid (conjHA); ns = not significant.

[0017] FIG. 5 shows fluorescein-conjugated OVD does not prevent IOL clarity. IOLS composed of hydrophobic acrylic (SA6AT5, MX60E). PMMA (CZ70BD), and hydrophilic acrylic (A060) were imaged under blue light, then submersed in 10% conjOVD. After 4 hours, the IOLs were removed from the OVD and rinsed in excess BSS. The IOLs were not stained by the fluorescein and were comparable to naive IOLs under blue light. The retained clarity of the optic was demonstrated through clear visualization of a printed letter under the optic. IOL = intraocular lens; OVD = ophthalmic viscosurgical device; conjOVD = OVD made with fluorescein-conjugated hyaluronic acid (conjHA).

[0018] FIGS. 6A-6E show proof-of-concept in an ex vivo model. (A) Proposed clinical workflow. (B) When the anterior chamber is filled with 5% conjOVD, a slight yellow hue can be seen on the iris under white light, which is not seen with 0% conjOVD. However, clarity of ocular structures is maintained. (C) An IOL is loaded into an injection cartridge filled with 5% conjOVD and injected into a porcine eye. (D) Under blue light, 5% conjOVD is clearly visualized in the anterior chamber. Importantly. conjHA allowed for visualization of OVD during removal via I / A. After removal of the I / A probe, retained OVD is seen extending from the peripheral angle (indicated with arrows). A second pass of I / A cleared this section of retained OVD. Images run left to right with time. (E) Green channel of (D). IOL = intraocular lens; I / A = irrigation / aspiration; OVD = ophthalmic viscosurgical device; conjOVD = OVD made with fluorescein-conjugated hyaluronic acid (conjHA).

[0019] FIGS. 7A-7C provide visualization of retained OVD following repeated I / A. (A) A short burst of I / A in the center of the anterior chamber clears much of visualized 5% conjOVD. However, a ring of conjOVD can be seen returning from the periphery of the anterior chamber within seconds of removal of the I / A probe. Images run left to right with time. Row 2 is the green channel of row 1. (B) Four successive rounds of I / A show the removal and retainment of 5% conjOVD. Less retained conjOVD is seen after each round of I / A. After the last round of I / A, no retained conjOVD is visualized. (C) Green channel of (B). I / A = irrigation / aspiration; OVD = ophthalmic viscosurgical device; conjOVD = OVD made with fluorescein-conjugated hyaluronic acid (conjHA).

[0020] FIG. 8 shows quantification of fluorescence intensity using ImageJ. Images were taken in a standardized fashion in a dark room under cobalt blue light. Images were split into RGB frames, green frames were split into quadrants (2x2), and intensity values for each quadrant were examined. OVD = ophthalmic viscosurgical device; conjOVD = OVD made with fluorescein- conjugated hyaluronic acid; RGB = red green blue.

[0021] FIG. 9 shows OVD mixed with unconjugated fluorescein did not prevent IOL clarity. lOLs composed of hydrophobic acrylic (SA6AT5, MX60E), PMMA (CZ70BD), and hydrophilic acrylic (A060) were imaged under blue light, then submersed in mixOVD. After 4 hours, the lOLs were removed from the OVD and rinsed in excess BSS. No visible fluorescence was appreciated. The retained clarity of the optic was demonstrated through clear visualization of a printed letter under the optic. IOL = intraocular lens; OVD = ophthalmic viscosurgical device; mixOVD = 0% conjOVD stained with 5 pg / mL fluorescein sodium.

[0022] FIGS. 10A-10B show routine histology' of porcine eyes injected with 0% or 5% conjOVD did not reveal remarkable differences in morphology. Brightfield images were taken of sections receiving Hematoxylin and Eosin (H&E) or Periodic Acid-Schiff (PAS) staining. (A) Cornea, including (i) comeal epithelium, (ii) comeal stroma, and (iii) comeal endothelium. (B) Ciliary structures, including (iv) iris and (v) ciliary processes. Scale bar in (A) and (B) = 500 pm.

[0023] FIG. 11 is a table of raw values of rheometry experimentation. Viscosity values are a mean of N = 3 replicates. Adj P value based on a two-way ANOVA with Bonferroni multiple comparisons test assessing the difference in viscosity between 0% and 10% conjHA at each shear rate tested.DETAILED DESCRIPTION

[0024] Some embodiments of the current invention are discussed in detail below. In describing embodiments, specific terminology is employed for the sake of clarity. However, the invention is not intended to be limited to the specific terminology' so selected. A person skilled in the relevant art will recognize that other equivalent components can be employed, and other methods developed, without departing from the broad concepts of the present invention. Allreferences cited anywhere in this specification are incorporated by reference as if each had been individually incorporated.

[0025] As used herein, the term ophthalmic viscosurgical device (OVD) refers to a transparent or translucent gel-like material that has been injected into an eye during ocular surgery'. The OVD maintains the volume and shape of the anterior chamber of the eye and protects the intraocular tissues during the procedure. Once injected, the OVD behaves like a device, maintaining its form even when penetrated by surgical instruments.

[0026] The phrase ‘'substantially free of any of said dye, fluorophore, luminophore, or quantum dot unconjugated to said polymer” means “substantially free” sufficiently such that boundaries of the OVD can be determined within a selected tolerance. In other words, this means the “boundaries” have acceptable tolerances of concentrations of unconjugated dye, fluorophore, luminophore, or quantum dot unconjugated to the polymer.

[0027] Accordingly, an ideal method to enable transient OVD visualization is through fluorescence, where a fluorophore emits light at a longer wavelength when excited with a shorter wavelength of light, or through luminescence, where light photons are directly emitted by a chemical reaction. When illuminated with a specified wavelength, the OVD could be visualized. When not illuminated, the OVD would remain clear.

[0028] The use of OVD stained with fluorescein is well established for use in research studies in porcine eye models.6’8In these models, OVD is admixed with fluorescein sodium until staining is complete. Then OVD is injected into porcine eyes to allow visualization of the OVD. This concept was included in a current US patent application, ‘‘FLUORESCENCE COLORING FOR EYE SURGERY” (Appl. No .: 17 / 240,650, filed 2021.04.26). This patent describes the injection of fluorescent dye into an eye during ocular surgery7. Second, this patent describes combining fluorescent dye with OVD for anterior segment eye surgery7. Finally, this patent describes a method to illuminate the eye during surgery to visualize the fluorescent dye. However, like the prior research utilizing this topic, the dye utilized is exclusive to fluorescein. Second, these studies only describe simply combining a fluorescent dye with OVD to stain the OVD. This bears the possibility7of fluorescein leaking from injected OVD and staining surrounding ocular fluids, materials, or structures, decreasing the confidence of this dye in exclusively visualizing thepolymer-based gel of OVD. Thirdly, only basic methods to visualize OVD are described. Finally, downstream applications of OVD visualization in clinical, operative, post-operative, quality control, and research applications are not extensively described.

[0029] By contrast, some embodiments of the current invention are directed to directly conjugating a fluorescent or luminescent moiety, "‘fluorophore” and ‘luminophore’; respectively, to the polymer backbone of OVD. Specifically, some embodiments of the current invention are directed to methods to chemically join a fluorophore or luminophore directly to the hydrophilic polymer of OVD, rather than simply mixing the two components for staining. This ensures the polymer backbone within OVD is visualized and provides confidence that conditional visualization is due to the presence of the polymer chains of OVD. and not due to any leaked or residual dye not in conjugation with the polymer.

[0030] Hyaluronate is a key component of many leading OVDs on the market today. Prior literature9has described the preparation of fluorescently -conjugated hyaluronate. Further, fluorescence-conjugated hyaluronate has been used in prior published research studies for visualization of hyaluronate in vitro and in vivo, in particular for biodistribution and cancer studies (murine). However, such a material has not been utilized for the production of OVD or for use in ocular surgery. As a consequence, applications of such a conjugated polymer in ocular surgery are yet to be commercialized or thoroughly explored. Other embodiments of the current invention are directed to the conjugation of other polymers used in the production of OVD, including chondroitin sulfate and hydroxypropyl methylcellulose, for example.

[0031] Some embodiments of the current invention also outline other moieties used for visualization of OVD in addition to fluorescein to be conjugated to the polymer backbone. Such additional embodiments of the current invention include both direct conjugation of vital dyes for continuous visualization as well as fluorescent or luminescent groups for transient visualization. These can include small molecule dyes as well as fluorescent and luminescent proteins, such as Green Fluorescent Protein (GFP).

[0032] Additionally, the aforementioned patent application only discussed the use of a microfibroscope to illuminate OVD to be visualized. Some embodiments of the current inventioninclude several operative and post-operative set-ups to visualize OVD within the eye intraoperatively and post-operatively.

[0033] Other embodiments of the current invention include methods to capture images and recordings of the visualized OVD, and uses thereof of this captured data. Specifically, utilizing fluorescence and luminescence to offer augmented-reality visualization to surgeons will be helpful to maximize discernment of residual OVD. Further, post-operative detection of fluorescence or luminescence will be helpful for prognosis and will offer insights for surgical quality improvement.

[0034] In addition, other embodiments include a method to quantify residual OVD is described. This may be detected as an intensity of fluorescence or luminescence, for example, as a total flux of photons of a specified wavelength. Additionally, a machine learning model can be trained to detect fluorescence or luminescence intensity via computer vision. This data can be utilized intraoperatively to guide further I / A by the surgeon, or post-operatively to inform the potential for complications, IOP spikes, and the potential need for re-intervention to remove residual OVD.

[0035] Therefore, the discussed embodiments of the current invention provide an outline of the components necessary to utilize conditionally visualized OVD in ocular surgery . Some embodiments include methods to illuminate the eye during and following surgery, as well as methods to quantify and utilize data from fluorescence or luminescence intensity. Further, some embodiments of the current invention include the production of OVD utilizing hydrophilic polymers chemically conjugated to fluorophores and / or luminophores, as opposed to prior art, which exclusively outlines mixing of fluorescein with OVD for visualization.

[0036] Some embodiments of the current invention can include the following:1. A method to enable visualization of ophthalmic viscosurgical device (OVD) during ocular surgery or following ocular surgery7wherein a dye, fluorophore, or luminophore is utilized. a. Wherein the OVD contains sodium hyaluronate, hyaluronic acid, chondroitin sulfate, and / or hydroxypropyl methylcellulose polymer or combinations thereof. b. Wherein the dye, fluorophore, or luminophore enables constant or conditional visualization of OVD.c. Wherein the dye, fluorophore, or luminophore is conjugated to the polymer chain. d. Wherein the dye. fluorophore, or luminophore is conjugated within the polymer backbone or conjugated as a substituent to the polymer backbone. e. Wherein the dye, fluorophore, or luminophore is conjugated to the polymer during synthesis of the polymer backbone or via subsequent reactions, conjugations, or modifications. f. Wherein the dye, fluorophore, or luminophore is conjugated to the polymer by at least one of covalent polymerization, co-polymerization, covalent modification, conjugate addition, Michael addition, azide-alkyne cycloaddition, mechanoradical coupling, click chemistry', streptavidin-biotin binding, and / or ionic binding. g. Wherein unconjugated dye, fluorophore, or luminophore is purified from the polymer during or after synthesis or conjugation. h. Wherein the dye is composed of a small molecule, such as trypan blue, try pan red, bengal red, azophlozin, or others. i. Wherein the fluorophore is composed of a small molecule or protein, such as fluorescein (fluorescein sodium, fluorescein isothiocyanate / FITC), methylene green, methylene blue, Green Fluorescent Protein (GFP), enhanced Green Fluorescent Protein (eGFP), Cyan Fluorescent Protein (CFP), Red Fluorescent Protein (RFP), Cyanine (such as IndoCyanine Green / ICG), biotin, rhodamine, rhodamine B, tetramethylrhodamine, tetramethylrhodamine isothiocyanate (TRITC). arylsulfonates, riboflavin, matlahne, and derivatives and combinations thereof. j. Wherein the luminophore is composed of 9-styrylanthracene, luciferin, luciferase, or others. A method of 1 wherein transient visualization of OVD is enabled via excitement of the fluorophore or luminophore conjugate of the polymer via illumination by ultraviolet or visual light. A method of 1 wherein transient visualization of OVD is enabled via application of a luminescent substrate. In particular, application of luciferin to luciferase-conjugated polymer in OVD, or application of luciferase to luciferin-conjugated polymer in OVD. a. Wherein the substrate, such luciferin is mixed with the OVD prior to use. b. Wherein the substrate is mixed within saline used during ophthalmic surgery'.c. Wherein the substrate is injected into the ocular chamber before, during, or following surgery . A method of 2 wherein illumination by ultraviolet or visual light is enabled by a light worn by an ophthalmic surgeon, in particular a surgeon’s headset or spectacles. A method of 2 wherein illumination by ultraviolet or visual light is enabled by a light manually held and directed at a patient’s eye. A method of 2 wherein illumination by ultraviolet or visual light is enabled by a light emitted by an operative microscope. A method of 2 wherein illumination by ultraviolet or visual light is enabled by a light following surgery7that is emitted by a diagnostic device. Wherein transient visualization of dyed, fluorescent, or luminescent OVD is enabled via direct observation or through observation through a camera and connected display. a. Wherein the camera is free-standing, hand-held, surgeon-worn, or within an operative microscope. A method of 8. wherein the camera digitally processes fluorescent or luminescent signal to increase visual exposure and enable effective visualization. A method of 9, wherein the recording image is presented as live film or a captured recording or image. a. Wherein increased exposure may improve visualization. b. Wherein live film is presented on an independent screen, overlayed via augmented reality within an operative microscope, or overlayed via augmented reality within a surgeon’s spectacles. c. Wherein captured images or recordings are stored and presented for later use, review, prognostics, or diagnostics. A system and method to quantify the amount of retained OVD through quantification of dye, fluorescence, or luminescence intensity. a. Wherein the intensity of fluorescence signal and / or flux of luminescence is recorded during or after surgery7. b. Wherein the signal captured is quantified relative to a baseline signal or otherwise. c. Wherein the signal captured informs further intraoperative removal of OVD, surgical review, post-operative prognostics, or post-operative diagnostics.d. Wherein detection of retained dyed, fluorescent, or luminescent OVD is informed via intraoperative or post-operative computer vision processing of captured images or film as in 8. e. Wherein a machine leaming / artificial intelligence software is employed to detect retained fluorescent or luminescent OVD in the ocular chamber. i. Wherein a trained model recommends further removal of OVD either intraoperatively or postoperatively.Scientific References. Tetz MR, Holzer MP. Two-compartment technique to remove ophthalmic viscosurgical devices. J Cataract Refract Surg. 2000;26:641-643. Miyazaki K. Saika S. Toxic anterior segment syndrome (TASS) — concentration of endotoxin in ophthalmic viscosurgical device. [Japanese], IOL & RS. 2009;23:59-61. Malvankar-Mehta MS, Fu A, Subramanian Y, Hutnik C. Impact of Ophthalmic Viscosurgical Devices in Cataract Surgery. J Ophthalmol. 2020 Oct 20;2020:7801093. final M. Yucel I. Sarici A, Artunay 0, Devranoglu K, Akar Y, Altin M. Phacoemulsification with topical anesthesia: resident experience. J Cataract Refract Surg. 2006;32: 1361-1365. Hashemi H, Mohammadpour M, Jabbarvand M, Nezamdoost Z, Ghadimi H. Incidence of and risk factors for vitreous loss in resident-performed phacoemulsification surgery. J Cataract Refract Surg. 2013 Sep;39(9): 1377-82. Oshika T, Okamoto F, Kaji Y, Hiraoka T, Kiuchi T, Sato M, Kawana K. Retention and removal of a new viscous dispersive ophthalmic viscosurgical device during cataract surgery in animal eyes. Br J Ophthalmol. 2006 Apr;90(4):485-7. Tanaka T, Kimura K, Usui M. Adhesive retention of sodium hyaluronate ophthalmic viscosurgical devices in an acrylic tube model and in porcine-eye corneal endothelium with different irrigation rates. J Cataract Refract Surg. 2009 Nov;35(l l):2008-13. Watanabe I, Yoshioka K, Takahashi K, Hoshi H, Nagata M, Matsushima H, Suzuki K. Advances in Understanding the Mechanism of Ophthalmic Viscosurgical Device Retention in the Anterior Chamber or on the Corneal Surface during Ocular Surgery. Chem Pharm Bull (Tokyo). 2021 ;69(6):595-599.9. de Beider AN, Wik KO. Preparation and properties of fluorescein-labelled hyaluronate. Carbohydr Res. 1975 Nov;44(2):251-7.

[0037] The following describes some embodiments in more detail. However, the broad concepts of the current invention are not limited to only these embodiments.

[0038] The purpose of the following examples is to develop and assess the utility of ophthalmic viscosurgical device (OVD) manufactured with fluorescein-conjugated hyaluronic acid (conjHA). The work was carried out in the Department of Biomedical Engineering and the Wilmer Eye Institute, Johns Hopkins University and School of Medicine. Baltimore, MD, USA.

[0039] ConjHA and unconjugated HA (unconjHA) at varied ratios were used to produce OVD (conjOVD) with varied fluorescence intensity'. The conjHA:unconjHA ratio was optimized to maximize clarity under white light and fluorescence intensity’ under cobalt blue light (CBL), allowing for conditional visualization. The effect of conjugation on conjOVD viscosity was assessed via rotational rheometry. Intraocular lenses (IOLS) yvere immersed in conjOVD for 4 hours to assess staining of lOEs. A proof-of-concept study yvas performed in ex vivo porcine eyes. Following injection and visualization, the OVDs were removed from the eyes via irrigation / aspiration (I / A).

[0040] Results: 0.5 mg / mL of conjHA (degree of substitution^).005) enabled robust fluorescence of conjOVD under CBL. Fluorescein-conjugation did not significantly affect conjOVD viscosity’ (P>0.05 for mean difference in viscosity at all shear rates tested). No staining of IOLs yvas appreciated. ConjOVD was visualized under CBL when injected ex vivo and maintained clarity of the anterior chamber under white light. Importantly, conjHA enabled delineation of retained OVD folloyving I / A.

[0041] Conclusions: Use of OVD composed of fluorescein-conjugated HA is a feasible method to enable conditional visualization of OVD intraoperatively yvithout nonspecific staining of ocular structures. Some embodiments can enable accelerated OVD removal in ocular surgery or decreased OVD retention folloyving surgery.INTRODUCTION

[0042] Ophthalmic viscosurgical devices (OVDs) are essential to modem cataract surgery, becoming ubiquitous with the operation. These viscoelastic hydrogels are used to maintain pressure within the anterior chamber, allow intraoperative compartmentalization of the eye, and provide needed protection of the comeal endothelium. However, OVD must be removed at the completion of surgery7via irrigation / aspiration (I / A), as retained OVD prevents drainage of ocular fluid through the trabecular meshwork, leading to increased intraocular pressure (IOP) in the hours and days following surgery.1'3Often, increased postoperative IOP is tnvial and resolves spontaneously. However, excessive OVD retention can lead to severe increases in IOP, comeal edema,4and patient discomfort.5Severe IOP increases may even be associated with trauma to the optic nerve.6Thus, assurance of OVD removal at the completion of surgery is of high clinical interest.

[0043] A key challenge to complete OVD removal is the difficulty7of OVD visualization during surgery. Commercially-available OVDs are clear hydrogels that can only be visualized intraocularly by examining faint boundaries between OVD and aqueous humor, making their discernment difficult. OVDs cannot be opaque, as it is necessary7for OVD to be clear during phacoemulsification and IOL insertion to enable visualization of ocular structures. This clarity7poses a challenge when OVD must be removed at the completion of a case. The first OVD (Healon) received FDA approval7in 1983, and its primary component of sodium hyaluronate, or hyaluronic acid (HA), remains the polymer of choice for the vast majority of OVDs today. Soon after the release of Healon, a version tinted with fluorescein sodium known as Healon Yellow, was developed. Tinting Healon with fluorescein does not contribute to significant side effects, comeal edema, or complications, but does facilitate OVD injection and removal.8,9Healon Yellow does not obscure ocular structures, but its yellow7hue can be difficult to discern against the red reflex. To solve this, Smith and Burt incorporated blue-light microscopy with the use of Healon Yellow, a technique they termed fluorescent viscoelastic enhancement (FVE),10which turned the OVD from clear yellow to brilliant opaque green under cobalt blue light (CBL). FVE minimized I / A time, which was proposed to potentially decrease endothelial cell loss. Importantly, FVE led to statistically significant decreases in postoperative IOP elevation.10However, the low7molecular weight of fluorescein allows its ready diffusion out of OVD leading to nonspecific staining of ocular structures. An alternative solution utilized high-molecular weight blue dextran to stain OVD, decreasing diffusion of the dye out of the OVD.11Blue-staining OVD improves itsdiscernment significantly but can obscure the surgical field. Further, this solution is not compatible with FVE.

[0044] de Beider and Wik developed fluorescein-conjugated HA (conjHA) in 1975 while working for Pharmacia.12Here, we utilize conjHA to produce OVD (FIGS. 2A-2C), a method that ensures any residual fluorescence following OVD removal is exclusively the result of retained polymers of OVD, and not due to nonspecific fluorescein staining. We hypothesize the use of fluorescence can be utilized to enable conditional visualization of OVD, wherein the OVD is largely clear during the majority of the operation under white light (WL), but clearly visualized when illuminated at the proper excitation wavelength when desired. This may allow surgeons to ensure complete OVD removal while avoiding unnecessary or risky I / A. We assessed the effect of this fluorescein-conjugated polymer structure on the material properties of this unique OVD, as well as whether IOLS can be inadvertently stained. Finally, we demonstrated the utility of this method using an ex vivo model.METHODS

[0045] This is a laboratory study that describes the production of conjOVD, which is then assessed for fluorescent and material properties in vitro and utility ex vivo.OVD Preparation

[0046] All OVDs were prepared at 10 mg / mL HA, 2 mg / mL sodium phosphate dibasic dihydrate (Sigma-Aldrich), 0.45 mg / mL potassium phosphate monobasic (Sigma-Aldrich), and 7.5 mg / mL sodium chloride (Sigma-Aldrich). Fluorescein-conjugated HA (conjHA. MW=1.5 million Da, degree of substitution, DS=0.005) and unconjugated HA (unconjHA, MW=1.5 million Da) were obtained from TdB Labs. Fluorescein-conjugated OVD (conjOVD) is prepared with various ratios of conjHA and unconjHA, expressed as percentage of conjHA. For example, 10% conjOVD contains 1 mg / mL conjHA and 9 mg / mL unconjHA. 0% conjOVD is used as anegative control. 0% conjOVD stained with fluorescein sodium (Liberty Scientific) at 5 pg / mL is used as a positive control. 0% conjOVD at 5 pg / mL fluorescein sodium (mixOVD) contains a fluorescein concentration approximately equivalent to 10% conjOVD. The solutions were stirred for 12 hours at room temperature to allow the HA to dissolve. All experiments were conducted within 24 hours of OVD production.OVD Characterization

[0047] The prepared OVDs were injected into a well plate and imaged in a standardized manner in a dark room under both WL and CBL. Images under CBL were split into Red-Green- Blue (RGB) channels. Green frames were parsed into a 2x2 matrix and analyzed for intensity values (ImageJ, v. 1.541). This allowed for semi-quantitation of green intensity that would be observed by surgeons through a filtered microscope (FIG. 8). A black background was used under CBL as is standard for visualizing fluorescence intensity7. Images under WL were taken with a white background. Printed letters were placed under the well plate to demonstrate visualization. OVD viscosity was assessed via rotational rheometry (MCR 302, Anton Paar) using a shear rate ramp at 25 °C.IOL Staining Assay

[0048] Hydrophobic acrylic (SA6AT5, Alcon and MX60E, Bausch & Lomb), PMMA (CZ70BD, Alcon), and hydrophilic acrylic (A060, Bausch & Lomb) IOLS were imaged under CBL with black background. Next, the IOLs were submerged in 10% conjOVD for four hours. Finally, IOLs were removed and rinsed with excess Balanced Salt Solution (BSS Sterile Irrigating Solution, Alcon). Images were again taken and compared with those of the naive IOLs. This experiment was then repeated with mixOVD.Ex Vivo Model

[0049] Porcine eyes were obtained from Sierra for Medical Science (Whittier, CA, USA). The eyes were illuminated with WL or CBL via the surgical microscope. When indicated. 5% conjOVD (0% conjOVD used as a control) was loaded into a syringe, and 300 pL was injected into the anterior chamber. Injected OVD was removed via I / A with a phacoemulsification machine (Centurion, Alcon). As a proof of concept, a hydrophobic acrylic IOL (SA60AT, Alcon) was loaded into a size D IOL injector (Monarch III, Alcon) filled with 5% conjOVD and injected intraocularly. When indicated, images of videos under CBL were split into RGB channels in ImageJ (v. l.54f) and green frames were presented. Eyes injected with 0% or 5% conjOVD were fixed five days in 10% neutral buffered formalin under refrigeration. Standard processing, sectioning, and staining (H&E, PAS) was performed by the Reference Histology Core at Johns Hopkins University followed by brightfield microscopy.Statistics

[0050] The intensity values (fold over background) of in vitro fluorescence were compared via one-way ANOVA with correction for multiple comparisons by two-stage step-up. A two-way ANOVA with Bonferroni multiple comparisons test and t test was used to assess rheological data. Significance assessed as P<0.05.RESULTS

[0051] ConjOVD was successfully produced with increasing fluorescence under CBL observed with increasing percentage of conjHA (FIG. 3A) and confirmed via image analysis (FIG. 3B). Except those noted, all comparisons were significant. The green intensity of 10% conjOVD and mixOVD were not significantly different, as was expected, given the concentrations of fluorescein in both samples are approximately equal. Green intensity of 5% and 10% conjOVD were not significantly different. These samples were placed over printed letters to assess their clarity compared to 0% conjOVD (FIG. 3C). All three conditions were clear under WL, with the letter easily visualized. A slight yellow hue is observed with 5% and 10% conj OVD, with the hue slightly greater in 10% conjOVD. Under CBL, both 5% and 10% conjOVD fluoresce intensely, but a printed letter can still be visualized through them. In order to maximize fluorescence under CBL and clarity under WL while minimizing fluorescein concentration, 5% conjOVD was used in subsequent ex vivo experimentation.

[0052] We next assessed the effect of fluorescein-conjugation on the material properties of the OVD produced. 0% conjOVD was used as a control against the highest concentration of conjOVD produced (10%). A shear-ramp curve demonstrates a characteristic shape expected from commercially-available13OVDs (FIG. 4A). Fluorescein-conjugation may have caused a subtle increase in OVD viscosity, as 10% conjOVD viscosity was an average of 6.4% SD 2.7) greater than 0% conjOVD at each of the shear rates tested (table of FIG. 11). No statistically significant difference in viscosity was observed between 0% and 10% conjOVD at any of the shear rates tested (FIG. 4A, FIG. 11). A shear rate of 1 sec-1is commonly examined as an industry standard, and a direct test comparing the viscosity of the two OVDs further found they were not significantly different (FIG. 4B).

[0053] As OVD is injected intraocularly during cataract surgery', it is important to verily that inadvertent staining of lOLs does not occur. lOLs were submerged in conjOVD at the highest concentration of conjHA produced (10%) for 4 hours, far in excess of the 10-minute duration of most cataract surgeries. After removing the lOLs from the OVD and rinsing with BSS, the lOLs did not exhibit fluorescence, with images under CBL comparable to naive lOLs (FIG. 5). Further, printed letters were placed under the optics, demonstrating preserved clarity. Submersion of the lOLs in mixOVD produced similar results (FIG. 9).

[0054] We next evaluated conjOVD in an ex vivo porcine model (FIG. 6A). 5% conjOVD was injected into the anterior chamber of a porcine eye. The anterior chamber remained clear under WL. Compared to 0% conjOVD, 5% conjOVD gave the iris a slight yellow hue under WL. However, this hue resolved upon removal of conjOVD via I / A (FIG. 6B). As conjOVD did not prevent visualization of ocular structures and given our findings that conjOVD did not stain lOLs (FIG. 5). we sought to test whether an IOL could be injected using a cartridge filled with conjOVD. In surgery, OVD enables both loading of lOLs into the injection cartridge and smooth insertion into the anterior chamber. This was successfully replicated using 5% conjOVD (FIG. 6C). Finally, we sought to determine if conjOVD could be effectively visualized intraocularly under CBL. When injected into a porcine eye, 5% conjOVD exhibited striking fluorescence under CBL. clearly delineating it from ocular structures. Notably, fluorescein-conjugation allowed visualization of OVD during removal via I / A. After a single pass of I / A, a portion of OVD remained within the porcine eye, seen extending from the peripheral angle. Further I / A successfully removed this portion of residual OVD (FIGS. 6D-6E).

[0055] Intrigued by the ability to visualize retained OVD, we sought to further investigate how conjOVD can be seen following I / A. 5% conjOVD was again injected into the anterior chamber of a porcine eye. and a brief burst of I / A was performed in the center of the anterior chamber without movement of the I / A probe. Much of the visualized conjOVD was quickly removed. However, within seconds of removal of the probe, retained conjOVD is seen extending back into the field of view of the anterior chamber (FIG. 7A). Finally, we assessed the visualization of conjOVD within the anterior chamber following subsequent, brief rounds of I / A. Following each round of 1 / A, lower quantities of conjOVD are seen returning to the field of view within the anterior chamber. After the fourth short burst of I / A, no retained conjOVD is visualized within the anterior chamber (FIG. 7B).

[0056] Routine histology of eyes injected with 0% or 5% conjOVD showed unremarkable differences in the cornea and ciliary structures (FIGS. 10A-10B). Injected OVD did not remain intraocularly following fixation and processing, and thus, residual fluorescence was not observed. No differences in the morphology of the corneal endothelium could be appreciated between 0% and 5% conjOVD.DISCUSSION

[0057] OVD retention remains a common issue in cataract surgery’ that can be largely attributed to the difficulty' in visualizing OVD intraocularly. Here, we developed an OVD utilizing a fluorophore covalently' bonded directly to HA, the primary component of most OVDs, ensuring I / A targets removal of the high-molecular weight polymers of interest, and not dye that has diffused from the OVD and stained ocular structures.

[0058] Rather than conjugating a traditional dye to the HA, which would lead to permanent visualization of the OVD, a fluorophore was used to enable conditional visualization. This allows clear visualization of ocular structures under WL. where conjOVD only displays a slight yellow hue. In fact, conjOVD was difficult to visualize intraocularly under WL, as with commercially - available OVDs. Under CBL, fluorescence was clearly observed both in vitro and ex vivo. Thus, in a clinical workflow, surgeons would be able to perform operations as normal under WL, then utilize CBL to visualize conjOVD during removal.

[0059] To produce the conjHA acquired for use in this study, fluorescein isothiocyanate is reacted with HA, producing a stable covalent bond. No free fluorescein is detectable in solution even when conjHA is incubated for a month at 37°C.12Thus, surgeons can be assured that residual fluorescence is emitted directly by retained HA, avoiding nonspecific staining observed when OVD is simply mixed with fluorescein sodium. Additional fluorophores have been conjugated to HA, such as tetramethylrhodamine, and could be evaluated in future research. Fluorescein was selected here given its known biocompatibility, safety, and current use in various ophthalmic procedures.14-16

[0060] Fluorescein-conjugation did not significantly affect the material properties of conjOVD. 10% conjOVD held an average of 6.4% increase in viscosity over 0% conjOVD at each of the shear rates tested. How ever, this difference was not statistically significant. The meandifference in viscosity between 0% and 10% conjOVD was 495. 1 mPa s at a shear rate of 1 sec'1, while a leading HA-based commercially-available OVD13holds an acceptable range of 40,000 mPa s under the same conditions. Thus, the variance in viscosity observed between 0% and 10% conjOVD is far within commercial tolerances and did not affect the progress of the study.

[0061] The nonsignificant changes to OVD viscosity from fluorescein-conjugation are perhaps not surprising, as only 5% conjHA with DS=0.005 was needed to achieve robust fluorescence. A more streamlined method of production would be to use HA conjugated to fluorescein uniformly at a lower DS, rather than using ratios of conjHA and unconjHA. For example, 100% conjOVD could be made using conjHA with DS=0.00025, thereby containing the same concentration of conjugated- fluorescein as 5% conjOVD with DS=0.005. Thus, rather than using ratios of conjHA and unconjHA to optimize florescence intensity, the DS can be optimized to produce conjOVD from a single batch of HA. Future work could conjugate fluorophores to other polymers used to produce OVD, such as chondroitin sulfate and hydroxypropyl methylcellulose.

[0062] Neither conjOVD nor mixOVD stained IOLS of three materials (hydrophobic acrylic, PMMA, hydrophilic acrylic) even following submersion for 4 hours. Our results follow previous work17demonstrating fluorescein does not stain IOLs composed of hydrophobic acrylic, silicone, or PMMA. However, it has been shown that free fluorescein can discolor hydrophilic acrylic IOLs, and thus, we initially hypothesized mixOVD may stain this material. This did not occur, which may be partially attributed to the use of fluorescein mixed in OVD rather than dissolved in water. Also, this prior study used substantially greater concentrations of fluorescein, at 100 mg / rnL, rather than 5 pg / mL used here. Thus, our results do not demonstrate adhered HA or fluorescein may not be detected in minute amounts with more advanced techniques. Rather, we have demonstrated that with sufficient irrigation, fluorescence cannot be visualized on the IOLs, and thus, we do not anticipate IOL staining will affect the progress of surgery using conjOVD, especially given the prior successful use of Healon Yellow, which contained free fluorescein.

[0063] We demonstrated successful visualization of retained conjOVD in an ex vivo model. Given this and prior work using stained OVD, we anticipate potential clinical benefits of conjOVD include (1) accelerated OVD removal, potentially decreasing operative times and the amount of I / A required, and (2) more complete OVD removal, decreasing severity and occurrence ofpostoperative IOP spikes. This may be of particular value in cases where IOP elevation is of increased concern, for example, in patients with prior history of glaucoma or optic nerve damage.2Further, the ability to visualize conjOVD under CBL carries the potential opportunity to (3) detect and quantify retained intraocular OVD intra and postoperatively. Finally, conjOVD may have particular benefits for (4) trainees first learning to remove OVD.

[0064] These anticipated benefits must be viewed in the context of the key limitation of this study, which was its use of ex vivo eyes. This prevented understanding of any unique consequences of fluorescein-conjugation on IOP elevation and long-term comeal health. Nevertheless, fluorescein-conjugation did not affect the comeal endothelium via histological examination. Given the ability of Healon Yellow with FVE to decrease postoperative IOP elevation,10we believe similar benefits may be replicated with conjOVD. Further, Healon Yellow has shown no adverse toxicity in vivo,8 0nor does the addition of fluorescein to Healon increase cytotoxicity to comeal cells in vitro.18However, the safety of OVD produced with conjHA needs to be fully verified in vivo. An additional limitation of porcine eyes is the difference in iris color with humans; given anecdotal reports that visualization of Healon Yellow^ varied with different color irises, future studies can assess visualization in a set of diverse human eyes. Nevertheless, the advantage of using CBL to visualize the OVD is that it does not depend on iris color. While we sought to determine the optimal concentration of conjHA to maximize OVD clarity under WL and visualization under CBL, it is likely this calibration will need to be adjusted in human studies, potentially with optimal concentrations for different eye colors.

[0065] In conclusion, here we developed and evaluated OVD composed of fluorescein- conjugated HA, which enabled striking visualization of OVD under CBL while maintaining a clear surgical field under WL. We demonstrated the potential clinical utility of this device ex vivo and conducted verification experiments needed to move towards eventual translation to the operating room. We anticipate this technology may enable improved efficiency, completeness, and safety of OVD removal, thereby improving patient outcomes in cataract surgery.

[0066] WHAT WAS KNOWNOphthalmic viscosurgical device (OVD) retention is a common issue in cataract surgery that is associated with negative outcomes, especially postoperative IOP spikes.While OVD clarity is needed to perform the operation, this makes removal challenging.Staining OVD may ensure its removal while minimizing excess irrigation / aspiration.• Previous work stained OVD with fluorescein, which allowed brilliant visualization using fluorescent enhancement. However, fluorescein can diffuse out of OVD and stain surrounding tissues.

[0067] WHAT THIS ADDS• OVD can be produced using fluorescein-conjugated hyaluronic acid (conjHA), allowing striking intraocular visualization of OVD under cobalt blue illumination while maintaining clarity of the anterior chamber under white light.• Conjugation of a fluorophore directly to HA assures residual fluorescence is emitted directly by the high-molecular weight polymers that compose OVD.• OVD produced with conjHA retains normal material properties of OVD and does not lead to visible staining of IOLS.

[0068] REFERENCES FOR EXAMPLES SECTION1. Arshinoff SA, Albiani DA, Taylor-Laporte J. Intraocular pressure after bilateral cataract surgery using Healon, Healon5, and Healon GV. J Cataract Refract Surg. 2002;28(4):617- 625.2. Grzybowski A, Kanclerz P. Early postoperative intraocular pressure elevation following cataract surgery. Curr Opin Ophthalmol. 2019;30(l):56-62.3. Malvankar-Mehta MS, Fu A, Subramanian Y, Hutnik C. Impact of Ophthalmic Viscosurgical Devices in Cataract Surgery. J Ophthalmol. 2020 Oct 20;2020:7801093.Briceno-Lopez C, Burguera-Gimenez N, Garcia-Domene MC, Diez-Ajenjo MA, Peris- Martinez C, Luque MJ. Corneal Edema after Cataract Surgery'. J Clin Med. 2023;12(21):6751. Dada T, Muralidhar R, Jhanji V. Intraocular pressure rise after use of Healon 5 during extracapsular cataract surgery. Can J Ophthalmol. 2007;42(2):338. Patel N, McAllister F, Pardon L, Harwerth R. The effects of graded intraocular pressure challenge on the optic nerve head. Exp Eye Res. 2018;169:79-90. Food and Drug Administration (FDA). Healon, Healon GV, Healon5 products sodium hyaluronate ophthalmic viscoelastic devices. Regulation number: 886.4275, 01 / 14 / 1983. Ohrstrbm A, Svensson B, Agrell B, Boos S, Calissendorff B. A dose titration study of fluorescein in sodium hyaluronate in ECCE with IOL implantation. Eur J Implant Refract Surg 1989;1: 19-22. Stenkula S, Ivert L, Berglin L, Crafoord S. Healon Yellow as a surgical tool in maneuvering intraocular tissues. Ophthalmic Surg. 1992;23(10):708-710. Smith KD, Burt WL. Fluorescent viscoelastic enhancement. J Cataract Refract Surg. 1992;18(6):572-576. Maison T, inventor; Pharmacia AB, assignee. Composition for ophthalmological use. U.S. Patent No. 4.764.360. August 16, 1988. de Beider AN, Wik KO. Preparation and properties of fluorescein-labelled hyaluronate. Carbohydr Res. 1975;44(2):251-7. ProVisc. Package insert. Alcon Laboratories, Inc.; 2014. McLaren JW, Brubaker RF. Measurement of fluorescein and fluorescein monoglucuronide in the living human eye. Invest Ophthalmol Vis Sci. 1986;27(6):966-974.15. Korb DR, Herman JP, Finnemore VM, Exford JM, Blackie CA. An evaluation of the efficacy of fluorescein, rose bengal, lissamine green, and a new dye mixture for ocular surface staining. Eye Contact Lens. 2008;34(l):61-64.16. Baddam DO, Ragi SD, Tsang SH, Ngo WK. Ophthalmic Fluorescein Angiography.Methods Mol Biol. 2023;2560: 153-160.17. Gerding H. Fluorescein Staining of Intraocular Lenses. Klin Monbl Augenheilkd.2018;235(4):369-372.18. Lindquist TD, Edenfield M. Cytotoxicity of viscoelastics on cultured comeal epithelial cells measured by plasminogen activator release. J Refract Comeal Surg. 1994;10(2):95- 102.

[0069] While various embodiments of the present invention have been described above, they have been presented by way of example only, and not limitation. Thus, the breadth and scope of the present invention should not be limited by any of the above-described illustrative embodiments but should instead be defined only in accordance with the following claims and their equivalents.

[0070] The embodiments illustrated and discussed in this specification are intended only to teach those skilled in the art how to make and use the invention. In describing embodiments of the disclosure, specific terminology is employed for the sake of clarity. However, the disclosure is not intended to be limited to the specific terminology so selected. The above-described embodiments of the disclosure may be modified or varied, without departing from the invention, as appreciated by those skilled in the art considering the above insights. It is therefore to be understood that, within the scope of the claims and their equivalents, the invention may be practiced otherwise than as specifically described. For example, it is to be understood that the present disclosure contemplates that, to the extent possible, one or more features of any embodiment can be combined with one or more features of any other embodiment.

Claims

WE CLAIM:

1. A kit for ocular surgery, comprising: a syringe comprising a needle having dimensions suitable for injecting an ophthalmic viscosurgical device OVD material to form an OVD in an eye for ocular surgery; a suitable amount of OVD material for forming said OVD loaded into said syringe; and instructions for suitable optical illumination to be used to observe said OVD, or a remaining portion thereof, at least one of during or after said ocular surgery based on a response of said OVD material to said optical illumination, wherein said OVD material comprises a polymer, wherein said OVD material comprises at least one of a dye, fluorophore, luminophore, or quantum dot conjugated to said polymer by at least one of covalent polymerization, copolymerization, covalent modification, conjugate addition, Michael addition, azi de-alkyne cycloaddition, mechanoradical coupling, click chemistry, streptavidin-biotin binding, ionic binding, or a combination thereof such that said at least one of a dye, fluorophore, luminophore, or a quantum dot remains attached within said OVD during or after said ocular surgery, and wherein said OVD material is substantially free of any of said dye, fluorophore, luminophore, or quantum dot unconjugated to said polymer.

2. The kit according to claim 1, wherein said polymer comprises at least one of sodium hyaluronate, hyaluronic acid, chondroitin sulfate, hydroxypropyl methylcellulose polymer or a combination thereof.

3. The kit according to claim 1 or 2, wherein said dye is a small molecule selected from the group of trypan blue, tr pan red, bengal red, and azophlozin, wherein said fluorophore is one of a small molecule or a protein selected from fluorescein, fluorescein sodium, fluorescein isothiocyanate (FITC), methylene green, methylene blue, Green Fluorescent Protein (GFP), enhanced Green Fluorescent Protein (eGFP), CyanFluorescent Protein (CFP), Red Fluorescent Protein (RFP), IndoCyanine Green (ICG), rhodamine, rhodamine B, Tetramethylrhodamine, Tetramethylrhodamine isothiocyanate (TRITC), arylsulfonates, riboflavin, matlaline, and derivatives and combinations thereof, and wherein said luminophore comprises 9-styrylanthracene, luciferin, or luciferase.

4. The kit according to any one of claims 1-3, further comprising a source of said suitable optical illumination.

5. The kit according to claim 4, wherein said source of said suitable optical illumination is configured to be worn by an ophthalmic surgeon in at least one of a headset or spectacles.

6. The kit according to claim 4, wherein said source of said suitable optical illumination is configured to be manually held and directed at a patient’s eye.

7. The kit according to claim 4, wherein said source of said suitable optical illumination is configured to be provided by a surgical microscope.

8. The kit according to any one of claims 1-7, further comprising a camera configured to detect light emitted from said OVD upon being illuminated with said suitable optical illumination.

9. An OVD material for injecting into an eye to form an OVD for ocular surgery, comprising: a polymer; and at least one of a dye, fluorophore, luminophore, or quantum dot conjugated to said polymer by at least one of covalent polymerization, co-polymerization, covalent modification, conjugate addition. Michael addition, azide-alkyne cycloaddition, mechanoradical coupling, click chemistry, streptavidin-biotin binding, ionic binding, or a combination thereof such that said at least one of a dye, fluorophore, luminophore, or a quantum dot remains attached within said OVD during or after said ocular surgery, wherein said polymer comprises at least one of sodium hyaluronate, hyaluronic acid, chondroitin sulfate, hydroxypropyl methylcellulose polymer or a combination thereof, andwherein said OVD material is substantially free of any of said dye, fluorophore, luminophore, or quantum dot unconjugated to said polymer.

10. The OVD material according to claim 9, wherein said dye is a small molecule selected from the group of trypan blue, tr pan red, bengal red, and azophlozin, wherein said fluorophore is one of a small molecule or a protein selected from fluorescein, fluorescein sodium, fluorescein isothiocyanate (FITC), methylene green, methylene blue, Green Fluorescent Protein (GFP), enhanced Green Fluorescent Protein (eGFP), Cyan Fluorescent Protein (CFP), Red Fluorescent Protein (RFP), IndoCyanine Green (ICG), rhodamine, rhodamine B, Tetramethylrhodamine, Tetramethylrhodamine isothiocyanate (TRITC), arylsulfonates, riboflavin, matlaline, and derivatives and combinations thereof, and wherein the luminophore comprises 9-styrylanthracene, luciferin, or luciferase.

11. A method of imaging an OVD or a remaining portion of an OVD in a patient’s eye, comprising: illuminating said patient’s eye with light having a wavelength suitable to effect light emission from said OVD or said remaining portion thereof; and imaging said light emitted from said OVD or said remaining portion thereof, wherein said OVD comprises: a poly mer, and at least one of a dye, fluorophore, luminophore, or quantum dot conjugated to said polymer by at least one of covalent polymerization, co-polymerization, covalent modification, conjugate addition, Michael addition, azide-alkyne cycloaddition, mechanoradical coupling, click chemistry, streptavidin-biotin binding, ionic binding, or a combination thereof such that said at least one of said dye, fluorophore, luminophore, or quantum dot remains attached within said OVD during or after said ocular surgery, wherein said polymer comprises at least one of sodium hyaluronate, hyaluronic acid, chondroitin sulfate, hydroxypropyl methylcellulose polymer or a combination thereof, andwherein said OVD is substantially free of any of said dye, fluorophore, luminophore, or quantum dot unconjugated to said polymer.

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