Choices abound among diverse phaco tips

New phaco tips offer improved fluidics regardless of surgeon’s technique or phaco system used.

Issue: February 1, 2000

Innovative technology has enabled phacoemulsification tips to facilitate improved fluidics inside the eye regardless of the surgeon’s technique or the phaco system employed, according to Stephen S. Lane, MD. “Obviously, there are advantages that are more significant with some tips as opposed to others,” Dr. Lane said, “and in that respect, surgeons will choose one tip over another.”

In the early days of phaco, degree of angulation was essentially the only decision surgeons had to make with regard to phaco tip choice. Most surgeons compromised using either a 30° or 45° tip. As the chopping techniques have become more popular, a shift toward flatter tips has taken place, with most surgeons using 0° to 15° tips that allow better holding power.

MicroFlow, ABS, MicroSeal tips

Singer LenQuake tip ---Singer LensQuake tip with 15° curve and 15° bevel up. Dr. Singer says since he has been using the LensQuake tip and technique, he has noticed fewer complications.

Today, elimination or reduction of incision burn and facilitation of increasingly smaller incisions are the impetus for a growing number of phaco handpieces and tips. For instance, Bausch & Lomb’s (Claremont, Calif.) MicroFlow needle follows up on the success of its predecessor, the MicroSeal, with additional features. The MicroSeal tip combines an internal sleeve that insulates the tip with an external sleeve that provides irrigation. The MicroFlow is a titanium needle with channels down the length of the needle, which is covered by a conventional silicone sleeve. It fits through a 2.6-mm incision.

“As the wound collapses around the silicone sleeve, it collapses along the portion of the needle between the channels, so the furrows stay open,” Dr. Lane said. “Fluid percolates through those channels, so that fluid flow is maintained in and out of the eye and that’s what prevents wound burn with that technology.”

The advantages of the MicroFlow are that it affords increased flow into the eye and less leakage, resulting in deeper chambers, and improved fluidics inside the eye, according to Dr. Lane. “Also, because of fluid flow down the channels, the needle is constantly cooled, preventing wound burns de-spite the tight incision wound. With a conventional needle and with this tight an incision, wound burns would be likely,” he said.

Dr. Lane relies exclusively on either the MicroSeal, the MicroFlow or an Aspiration Bypass System (ABS; Alcon, Fort Worth, Texas) needle. “I use one of those three routinely in every single case that I do. They lead to a very stable internal environment,” he said.

Pennsylvania cataract surgeon E. Ronald Salvitti, MD, relies on Alcon’s flared ABS tip, which he has used exclusively for 1.5 years. The flared ABS tip has a small hole near the neck of the flared portion, allowing for continuous movement of fluid through the shaft of the needle, even at the time of tip occlusion. This bypass opening reduces post-occlusion surge and adds to the cooling process of the tip during emulsification. “The fact that the flared tip has a larger opening with a narrow bore allows use of higher vacuum and higher aspiration flow levels. I get better occlusion as the higher parameters are applied. The narrow shaft of the flared tip allows for a larger column of fluid to exist between the sleeve and the shaft. This adds to the cooling potential and also provides an immediate availability of fluid, reducing post-occlusion surge,” Dr. Salvitti said.

“Over the years, Alcon has done much to improve the technology of the phaco machine, allowing individual control of flow rates and vacuum levels, with improved ultrasound. Now with the availability of this new tip design, we have another favorable change in our phaco technology,” Dr. Salvitti said.

Gold Standard Sleeve

--- Singer LensQuake tip with hexagon shape induces a disturbance in the lens nucleus that simulates a miniature earthquake.

Surgin Inc.’s (Tustin, Calif.) Gold Standard Sleeve is an example of a system that offers the incision protection provided by an insulated stent inside an infusion sleeve, the ability to fit through incisions of less than 2.5 mm and the convenience of being equally efficient when used with a variety of phaco systems, including Allergan’s (Irvine, Calif.) Diplomax, Bausch & Lomb’s Protégé and Alcon’s Legacy, according to Oklahoma ophthalmic surgeon John Belardo, MD. “The insulated sleeve allows surgeons to enter small incisions of 1.9 mm and 2 mm without difficulty, and it maintains flow and cooling of the needle,” Dr. Belardo said. “As we’re going down into these smaller incisions of 2.5 or 2 mm, you want that extra margin of safety.”

According to Dr. Belardo, studies have shown that with 100% ultrasound power, the Surgin needle never rose above 40°C. He said it takes 60°C to cause corneal burns.

Zero Degree, Laminar tips

---Singer LensQuake tip with external hexagon shape and circular lumen. Dr. Singer says with this tip, nucleus removal is one of the easiest parts of the procedure.

Boston ophthalmic surgeon Roger Steinert, MD, likes Allergan’s Zero Degree tip because the tip has properties that are highly beneficial for phaco chop. “The Zero Degree tips occlude most easily because they have the smallest area that needs to be occluded for vacuum to be able to build,” he said. “In addition, the Allergan Zero Degree has an internal bevel that other 0° tips do not have. The bevel sharpens the edge so the Zero Degree can be effective on even 4+ nuclei, and it creates cavitation effects that dramatically improve phaco efficiency,” he said.

Something new from Allergan is the Laminar small incision tip, which Dr. Steinert recently evaluated. The phaco tip diameter is 20 gauge, which he said behaves as efficiently as conventional 19 gauge, and the sleeve has very low friction in the tissue, which allows it to move freely through a tight wound. “As a result,” Dr. Steinert said, “I was able to phaco through a 2.3-mm wound with no irrigant leakage and with maximal efficiency.”

Hard-Rock LensQuake tip

photograph ---When the phaco tip is advanced into the center of the nucleus and is occluded, vacuum energy and the wedge shape of the tip induces stress and strain near the y-sutures resulting in lensquake induction.

A needle that has the ability to cut through extremely dense nuclei is Surgical Design’s (Long Island City, N.Y.) Hard-Rock LensQuake tip. Like its predecessor, the LensQuake tip, de signed by Vermont surgeon Jack Singer, MD, the Hard-Rock Lens Quake, also designed by Dr. Singer, utilizes a hexagon-shaped or diamond-shaped phaco tip to induce a disturbance in the lens nucleus that simulates a miniature earthquake, Dr. Singer said. The Hard-Rock Lens Quake, however, has a double bevel that cuts through rock-hard nuclei in order to get down to the level where it needs to be. “The lens quake can be propagated along nuclear fault lines that run from the y-sutures to the equator and the posterior pole,” Dr. Singer said. “Using this method, the nucleus can be cracked from the center to the periphery without the need to place a sharp chopping instrument near the equator of the lens.”

Dr. Singer said that since he has been using the LensQuake tip and technique, he has noticed fewer complications, such as torn zonules or capsules, and a decreased operative time. “It almost seems,” he said, “as though the nucleus removal is one of the easiest parts of the procedure now.”

Wave phaco system

photograph --- A simple manipulation will propagate the lensquake to the posterior pole and to the equators.

STAAR Surgical’s (Monrovia, Calif.) Wave phaco system has some unique features with regard to tip technology. Most important, says California cataract surgeon Stephen S. Bylsma, MD, is the frequency with which it is tuned. “The Wave checks the precision of its frequency about 10 times more frequently than with standard phaco tips,” Dr. Bylsma said. “What that leads to is a very consistent standard of ultrasound, and it translates into a very efficient cutting device, so the efficiency of the tip is much greater than most.”

The other aspect that is fairly unique is that there are three different size tips ranging from 19 through 21 gauge. The 21-gauge tip enables surgeons to perform phaco in incisions smaller than 2 mm. “That, combined with the new cartridge delivery system from STAAR (model 4207) and the soon to be released Collamer IOL, allows the entire procedure to be performed in a 1.8- or a 1.9-mm incision,” he said.

Nd:YAG laser phaco

photograph ---Slide the nucleus manipulator downward along the side of the stationary phaco tip and then move the phaco tip slightly forward and the nucleus manipulator slightly backward to produce a strike-slip fault, sliding the nuclear segments past each other horizontally. This will induce complete propagation of the lensquake to the posterior pole and to the equators.

Long-awaited laser phaco technology has emerged with the advent of Paradigm Medical Industries Inc.’s (Salt Lake City) Photon System, an Nd:YAG laser that is currently in clinical trials. Lead investigator Michael B. Limberg, MD, of San Luis Obispo, Calif., said the Photon tip works by “bringing light along a fused silicon fiber optic.” The light interacts with the lens material to produce both a photo-acoustic and a photo-thermal effect to both soften the lens and to acoustically break it up, according to Dr. Limberg.

The laser holds the potential for being a much more benign and controllable procedure than ultrasound phaco, according to Dr. Limberg. “It’s not a vibrating needle in the eye, such as you have with ultrasound, where you can readily break the capsule. You can fire the laser directly onto the capsule repeatedly without doing any damage because the laser light is not absorbed by the capsule,” Dr. Limberg said. “It’s gentle, cooler, and requires less control of the tip because there is an element of freedom in not having to worry about damaging the capsule or iris,” he said.

Paradigm recently announced its submission of a “notice of intent to market” in addition to recent clinical trial results of the Photon System to the Food and Drug Administration for approval. Company officials believe the approval will be expedited.

Centauri Er:YAG laser phaco

The development of erbium:YAG laser cataract surgery by EyeSys Premier (Irvine, Calif.) opens new vistas with regard to phaco tip technology. EyeSys Premier’s Centauri laser delivers infrared energy by means of an optical fiber to a sapphire tip that has a spherical apex to focus the energy in the lens nucleus. There are three paracentesis incisions into the eye for the surgical procedure: one for infusion, one for aspiration and the last to deliver laser energy into the lens nucleus.

“What we are doing at the EyeSys Premier laser is to separate these three functions to minimize the size opening. The next generation of lens implant technology will hopefully be an accommodating IOL. This will require even smaller incisions than what we have right now,” said John Hunkeler, MD, a Centauri laser clinical trial investigator. “As we move toward even smaller incisions, this should be the stimulus for continuing improvement in lens implant technology.”

American Optisurgical Inc. (AOI; Irvine, Calif.) addresses the cataract surgeon’s desire to streamline expenses. The company refurbishes phaco handpieces. Equipment that is refurbished by AOI has a complete line of phaco tips and compatible phaco accessories. The company provides replacement and/or refurbish for a wide range of phaco equipment and manufactures with OEM quality standards.

For Your Information:

John Belardo, MD, can be reached at 1210 Lynnwood Drive, Elk City, OK 73644; (580) 225-7833; fax: (580) 243-5322. Dr. Belardo has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.

Stephen S. Bylsma, MD, can be reached at 1414 E. Main St., Santa Maria, CA 93454; (805) 925-2637; fax: (805) 347-0033. Dr. Bylsma has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for STAAR Surgical Co.

John Hunkeler, MD, can be reached at 4321 Washington Blvd., #6000, Kansas City, MO 64111; (816) 931-4733; fax: (816) 931-9498. Dr. Hunkeler did not disclose whether or not he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.

Stephen S. Lane, MD, can be reached at 232 N. Main St., Stillwater, MN 55082; (651) 439-8500; fax: (651) 439-5106. Dr. Lane has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Alcon and Bausch & Lomb.

Michael B. Limberg, MD, can be reached at 1270 Peach St., San Luis Obispo, CA 93401; (805) 541-1342; fax: (805) 541-5836. Dr. Limberg did not disclose whether or not he has a direct financial interest in any of the products mentioned in this article or if he is a paid consultant for any companies mentioned.

E. Ronald Salvitti, MD, can be reached at 750 E. Beau St., Washington, PA; (724) 228-2982; fax: (724) 228-8117. Dr. Salvitti has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Alcon.

Jack A. Singer, MD, can be reached at 40 S. Main St., Randolph, VT 05060; (802) 728-2460; fax: (802) 728-3407. Dr. Singer has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Surgical Design.

Roger F. Steinert, MD, can be reached at 50 Staniford St., Boston, MA 02114; (800) 635-0489; fax: (617) 573-4912. Dr. Steinert has no direct financial interest in any of the products mentioned in this article. He is a paid consultant for Allergan Inc.

Alcon can be reached at 6201 South Freeway, Fort Worth, TX 76134; (800) 862-5266; fax: (800) 241-0677.

Allergan Inc. can be reached at 2525 Dupont Drive, Irvine, CA 92612; (714) 246-4882; fax: (714) 246-2440.

American Optisurgical Inc. can be reached at 19 Hammond, Ste. 505, Irvine, CA 92618; (800) 576-1266; fax: (949) 580-1270.

Bausch & Lomb Surgical can be reached at 555 W. Arrow Highway, Claremont, CA 91711; (800) 338-2020; fax: (909) 399-1422.

EyeSys Premier Systems can be reached at 3 Morgan, Irvine, CA 92618; (949) 859-0656; fax: (949) 951-7218.

Paradigm Medical Industries Inc. can be reached at 1127 West 2320 South, Ste. A, Salt Lake City, UT 84119; (801) 977-8970; fax: (801) 977-8973.

STAAR Surgical Co. can be reached at 1911 Walker Ave., Monrovia, CA 91016; (626) 303-7902; Fax: (626) 359-8402.

Surgical Design can be reached at 4523 21st St., Long Island City, NY 11101; (718) 392-5022; fax: (718) 786-2139.

Surgin Inc. can be reached at 14762 Bentley Circle, Tustin, CA; (714) 832-6300; fax: (714) 832-0300.