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Micro-incision cataract surgery improves safety, surgeon says
Bimanual separation of irrigation and aspiration functions into two hand pieces allows the use of smaller incisions.
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ALICANTE, Spain – Micro-incision cataract surgery can improve safety and reduce trauma for cataract patients, according to a surgeon here. However, certain modifications must be made to further improve the surgery, he said.
Minimum incision cataract surgery (MICS) can now be performed through an incision of 1.5 mm or less, said Jorge L. Alió, MD, PhD, of the Instituto Oftalmologíco de Alicante here. The eventual goal for the surgery is an incision of 1 mm or less.
The smaller incision allows faster recovery and less disruption of tissue. He said the equipment to operate through smaller incisions is available, but better fluidics will make the surgery safer.
MICS is now routine for Dr. Alió, who performs cataract removal and IOL insertion through a 1.5-mm incision in about 40% to 50% of his cases with cataract grades of 1 to 4. He uses a prefolded, 6-mm optic lens that fits through the small incision.
Until the ability to control fluidics is improved, however, he said he cannot operate on higher grades of cataract or through smaller incisions.
“MICS is the new challenge for cataract surgery. The concept is part of the normal evolution of cataract surgery. It will be the stimulus for the development of new technologies and IOLs,” he said.
Dr. Alió spoke of five needs for implementing MICS routinely in more cases: optimization of fluidics, development of bimanual separation of irrigation and aspiration, design of new instruments for new tasks, using lasers for cataract surgery and improving ultrasound phacoemulsification probes.
“The ultimate goal of MICS is to create a safer cataract surgery in a closed environment with an IOL to fit a 1.5-mm incision or less,” he said.
Separation of functions
Dr. Alió adopted the MICS approach a year and a half ago when he began using the Dodick Photo-Lysis laser system (ARC Laser) for removal of some cataracts. The technology allowed him to use separate incisions for irrigation and for the laser probe.
“The separation of functions was an important finding. … From this we started to think about how to use phacoemulsification for harder nuclei that were left by the phaco laser. We started to use the phaco probe for this purpose, having only the phaco probe with the aspiration in one incision and the irrigation in the other incision,” he said.
According to Dr. Alió, the separation of I&A functions is necessary for better control of fluidics. Optimizing fluidics allows the surgeon to stabilize the anterior chamber and avoid reflux.
There must also be a mechanism that responds quickly to changes in anterior chamber pressure to eliminate surge, he said.
Instruments and technique
Dr. Alió said there is a need for customized instruments that can be combined with the separate irrigation and aspiration functions. For example, an irrigation instrument combined with a chopper could be useful. Other instruments already exist that can be used through 1 mm incisions, such as intraocular manipulators and forceps originally designed for posterior segment use.
Dr. Alió currently uses two IOLs in his MICS cases. AcrySmart (Acritec) and ThinOptx (ThinOptx Inc.) IOLs are both 6-mm optic lenses prefolded to fit through the 2-mm incision. Once implanted, the lenses unfold in either 10 seconds or 20 minutes, depending on the technology. To ensure proper placement, the patient is examined under the slit lamp after surgery.
Dr. Alió said a bimanual approach is needed for MICS.
“We should work with more than one instrument in each hand. As other instruments come together with these functions (I&A), it will make a better surgery,” he said.
Control of power during MICS is essential, he said. He uses the Accurus (Alcon) and the ARC (ARC Laser) phacoemulsifier for hard nuclei and the Dodick PhotoLysis Nd:YAG laser for soft nuclei.
For Your Information:
- Jorge L. Alió, MD, PhD, can be reached at Instituto Oftalmológico de Alicante, Adva, Dénia 111, 03015 Alicante, Spain; (34) 96-515-4062; fax: (34) 96-515-1501; e-mail: jlAlió@oftAlió.com. Dr. Alió has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- ARC Laser Corp., distributor of the Dodick Laser PhotoLysis System, can be reached at 2417 South 3850 West, Salt Lake City, UT 84120; (801) 972-1311; fax: (801) 972-5251; Web site: www.arclaser.com.