Manual cataract instruments reign despite impending femtosecond revolution

Advances include systems that stabilize the eye, boost the accuracy of limbal relaxing incisions and toric IOL centration, and optimize phaco safety.

Cataract surgeons have a vast array of instruments at their disposal to perform intricate procedures with increasing speed, safety and efficiency.

Steady technological advances have firmly established cataract surgery as an essentially refractive procedure that offers optimal outcomes amid rising patient expectations.

Femtosecond laser-based cataract techniques are garnering keen interest in the United States. However, new and improved devices promise to bolster the safety and efficacy of manual and power-assisted techniques. At best, current femtosecond laser technology can only augment established methods.

R. Bruce Wallace III

“For now, most of us will still be using standard phacoemulsification for a while,” OSN Cataract Surgery Board Member R. Bruce Wallace III, MD, said. “We are still going to encounter some [grade] 3 and 4-plus nuclei and we can break those up, but they are not going to be aspirated by the laser, so we are going to have to have phacoemulsification capability available to us, but with less energy and more safety.”

While femtosecond lasers have shown the potential to enhance surgical safety and predictability, the cost of adopting the new technology is prohibitive for many practices.

“The biggest question is, will the advantages of new technology outweigh the disadvantages of increased time and cost? Once femtosecond cataract technology becomes readily available, increased usage and prospective studies will answer that question.” Bonnie An Henderson, MD, OSN Cataract Surgery Board Member, said.

OSN Cataract Surgery Section Editor Rosa Braga-Mele, MD, FRCSC, predicted that cost will hinder the adoption of femtosecond technology in the near term.

“The main limiting factor with the femtosecond will be cost,” Dr. Braga-Mele said. “Somewhere down the road, [femtosecond technology] will be the future incision-making tool for corneal incisions and limbal relaxing incisions.”

Marking and stabilization

Corneal marking systems are in current use to enhance the accuracy of limbal relaxing incisions and toric IOL placement.

Bonnie An Henderson

“Toric instrumentation has really exploded,” Dr. Henderson said. “There are lots of new, novel instruments to mark the eye, with the recent increased interest in astigmatism management.”

Dr. Wallace said that a capsulotomy diameter-marking technique prevents posterior capsule opacification and optimizes IOL placement and power calculation.

“Obviously, with femtosecond lasers, this may become a relatively obsolete instrument,” Dr. Wallace said. “However, I still think we’re going to be doing some anterior capsulotomies regardless of what the lasers offer because we are still going to see some small pupils from time to time and have difficulty.”

The arsenal of marking tools also includes the Henderson Marking System (Katena), degree-gauge marking system (Mastel Precision), Dell Marker (ASICO) and Devgan Axis Marker (Accutome).

The Singer TriPort (Mastel) stabilizes the globe before IOL placement and the creation of a clear corneal incision or side-port incision.

“The TriPort is a unique instrument created by Jack Singer that can be used to hold and manipulate the eye,” Dr. Henderson said. “It stabilizes the globe to make the side-port incision and then can be used to enter the newly created side port to stabilize the globe for the clear corneal wound.”

Diamond and steel blades

The choice of blades is particularly critical because all surgical procedures hinge on incisional integrity.

Dr. Wallace helped develop the Wallace-Maloney diamond knife, which is available from Rein Medical, Storz and Duckworth & Kent.

“It allows you to make the side-port incision and to stabilize the globe to make the phaco incision without having to add viscoelastic prior to making the phaco incision,” Dr. Wallace said.

Dr. Braga-Mele recommended high-end diamond blades for procedures that require thin, accurate cuts.

“The thinner the blade, the better the blade,” she said. “And the better the cut, the better it heals. For [limbal relaxing incisions], you are going to get a bigger bang for your buck with a higher-end diamond blade.”

Stainless steel blades are a viable alternative for many cost-conscious surgeons.

“There are many companies that manufacture good-quality disposable stainless steel knives,” Dr. Henderson said. “They offer various shapes and sizes with different cutting edges. Fortunately, there are many to choose from at this point.”

Enhanced phaco safety

Recent innovations in phacoemulsification technology include re-usable silicone and disposable polymer irrigation and aspiration tips for the OZil Torsional Handpiece, a component of Alcon’s Infiniti phacoemulsification platform.

“In the face of a lot more issues with [toxic anterior segment syndrome] infections, it is nice to have a disposable I&A tip,” Dr. Braga-Mele said. “It also increases the efficiency and safety of the procedure because with the silicone sleeve, the wound is really nice and tight and the chamber is well-formed. And they are capsule-friendly.”

Dr. Wallace helped develop the Wallace Guardian (Storz), a blunt chopper that protects the posterior capsule during the removal of nuclear lens fragments. – by Matt Hasson

• Rosa Braga-Mele, MD, FRCSC, can be reached at 245 Danforth Ave., Suite 200, Toronto, Ontario M4K 1N2, Canada; 416-462-0393; e-mail: rbragamele@rogers.com. Dr. Braga-Mele is a consultant for Alcon but has no proprietary interest in any of the products mentioned.
• Bonnie An Henderson, MD, can be reached at Ophthalmic Consultants of Boston, 52 Second Ave., Waltham, MA 02451; 781-487-2200; e-mail: bahenderson@eyeboston.com. Dr. Henderson is a consultant for Alcon but has no financial interest in any of the products mentioned in this article.
• R. Bruce Wallace, MD, FACS, can be reached at Wallace Eye Associates, 4110 Parliament Drive, Alexandria, LA 71303; 318-448-4488; fax: 318-448-9731; e-mail: rbw123@aol.com. Dr. Wallace is a consultant for Bausch + Lomb, Abbott Medical Optics, Allergan and LensAR, but has no financial interest in any of the products mentioned in this article.

With the new, small-gauge phaco tips and phaco platform software, upgrading to microincisional cataract surgery (MICS) is easy for the surgeon because the surgical technique can be kept the same. With more and more microincision IOLs coming to market, there is a definite benefit to MICS because smaller incisions seal better, allow more control and induce less astigmatic change. If you have not tried MICS yet, now is the time.

– Uday Devgan, MD, FACS
OSN SuperSite Section Editor
Disclosure: Dr. Devgan is a consultant to Bausch + Lomb but has no financial interest in the Stellaris Elite website.