New cataract instruments boost safety and visual, refractive outcomes

Innovations include a YAG laser designed to prevent posterior capsule opacification, a disposable I & A tip and a phaco pulse control component.

Advancing technology continues to raise the bar for cataract surgery. Developments in hand-held instrumentation and laser technology promise to help surgeons maximize visual and refractive outcomes and safety.

Ongoing innovations address daunting complications such as capsule opacity, ocular infection and corneal injury. These developments also help surgeons meet patients’ rising expectations.

George O. Waring

A new laser innovation addresses posterior capsule opacification, a common long-term complication of premium IOL implantation, George O. Waring III, MD, FACS, FRCOphth, said.

“Opacification of the capsule after a successful surgery and successful lens implantation is what I would call the last remaining question in cataract surgery,” Dr. Waring said.

Overall developments in torsional phacoemulsification enable better control of the anterior chamber and enhance safety, Steve A. Arshinoff, MD, FRCSC, OSN Cataract Surgery Board Member, said.

“It will allow us to lower our flow parameters. If we lower our flow parameters, then we have healthier corneas after surgery,” Dr. Arshinoff said.

Bonnie An Henderson, MD, OSN Cataract Surgery Board Member, noted the wide array of new and existing instruments on the market.

“Several companies are coming out with new, exciting products that may improve outcomes or increase safety,” Dr. Henderson said.

Nd:YAG laser for PCO

The Dodick Nd:YAG Laser Photolysis system (A.R.C. Laser) is entering a European clinical trial for the removal of lens epithelial cells that cause PCO, Dr. Waring said. The laser received U.S. Food and Drug Administration approval for cataract surgery in 2000.

“It was invented to take cataracts out through a 1-mm incision,” he said. “That really hadn’t worked out very well. Phaco got a lot better fast. But it turns out that this instrument can remove the lens epithelial cells and they don’t grow back.”

The laser has a handpiece and a 1-mm or 1.5-mm probe that is inserted through a paracentesis to remove cells from the capsule nasally and temporally. The surgeon may create two paracentesis wounds or work through an existing wound used for phacoemulsification and create another wound to gain access to the capsule, Dr. Waring said.

A shock wave, not the Nd:YAG laser beam, removes cells from the capsule. Application of the laser adds only about 5 minutes to the overall procedure, Dr. Waring said.

Use of the laser offers advantages such as preventing the need for a second operation. Opening the capsule to remove lens epithelial cells diminishes capsule support and increases the risk of retinal detachment. In addition, preventing PCO is vital to the long-term outcomes of multifocal and accommodating IOLs, which are more vulnerable to opacity than monofocal lenses, Dr. Waring said.

The prospective, randomized, masked clinical trial is scheduled to commence at five centers in Europe later this year or in early 2010.

Three-year results of a study on the laser application are scheduled to be published in the Journal of Cataract and Refractive Surgery in 2010, Dr. Waring said.

Disposable tip, IOL cutter

Dr. Henderson said Alcon’s single-use, disposable irrigation-aspiration tip was launched at the American Academy of Ophthalmology meeting in San Francisco.

Bonnie An Henderson

“The reason this is interesting is that it’s made of a soft polymer material, which is capsule-friendly,” Dr. Henderson said. “And the fact that it’s a disposable tip with no worry of improper sterilization and no worry of cross-contamination may decrease the likelihood of developing a postoperative complication like TASS.”

The disposable tip is available with a 35° bent tip, a 20° curved tip and a straight tip. It is suitable for microincision surgery as well as larger incision phacoemulsification surgery, Dr. Henderson said.

“It has a very gentle, smooth rounded tip that should be easy to learn how to use without a steep learning curve,” she said.

Another new instrument, the Stolte Soft IOL Cutter (Katena), is designed to enable surgeons to safely cut an IOL inside the eye and remove it during IOL exchange surgery, Dr. Henderson said.

“It appears to be a very stable device that will decrease some of the traumatic events that may occur when attempting to remove an IOL from the eye,” she said.

Torsional phaco adjunct

An add-on software component to Alcon’s Infiniti torsional phacoemulsification platform, OZil Intelligent Phaco (IP) is particularly useful in fragmentation of dense lenses, Dr. Arshinoff said.

Steven A. Arshinoff

Alcon introduced the OZil IP software at the AAO meeting.

The IP software automatically senses occlusion of the phaco tip and directs the machine to emit an axial pulse to shatter the lens, Dr. Arshinoff said.

“You only build vacuum in peristaltic phaco machines when you have occlusion of the tip,” he said. “So, if the phaco is not being effective, then the tip just stays occluded if it’s a dense lens. The machine is designed to sense the level of occlusion that you ask it to sense. You can set the IP phaco for 100% of the vacuum or 90%, or whatever you like. So, when it gets to that point, it will kick in some axial pulses to sort of bounce the lens off and shatter it.”

IP will help surgeons who are unaccustomed to handling dense lenses, Dr. Arshinoff said. – by Matt Hasson

Click here for the Guide to Hand-held Cataract Instruments and Capsular Tension Rings

• Steve A. Arshinoff, MD, FRCSC, can be reached at 2115 Finch Ave. W, Suite 316, Toronto, Ontario M3N 2V6, Canada; 416-745-6969; e-mail: ifix2is@sympatico.ca. Dr. Arshinoff is a consultant for Alcon and Carl Zeiss.
• 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 and ISTA Pharmaceuticals.
• George O. Waring III, MD, FACS, FRCOphth, can be reached at InView, 300 Perimeter Center N, Suite 600, Atlanta, GA 30346; 678-222-5102; e-mail: drgeorge@georgewaring.com.

Using a laser to remove lens epithelial cells may help us in minimizing capsular contraction problems; however, the law of unattended consequences being what it is, only time will tell if this adds anything to present technologies. Might an acellular capsule allow spontaneous IOL dislocation in motion injuries? Less obvious issues have occurred in my career already so let’s see how this turns out.

A one-time use I & A tip and even one-time use surgical instruments as a defensive step to prevent TASS make sense, with many now in France doing this on a regular basis. In the U.S., pressure on cost, with all reimbursement not keeping up with inflation and likely to get worse, will be the major issue slowing down adoption of more disposables.

IP is a smart move because tip clogging with hard cataracts with 100% transverse ultrasound is a nagging problem. I predict rapid adoption of this new software, particularly in areas where hard cataracts are a common occurrence.

On Oct. 22, the Ophthalmology Innovation Summit was held at the Palace Hotel in San Francisco. Twenty-five start-up companies covering the breadth of ophthalmology were given 10 minutes to state their case to a full audience. In the cataract field it was clear that the major concepts presented were regarding greater refractive accuracy (ie, ORange Intraoperative Aberrometer) accommodative IOLs with 10 D+ range of action (ie, NuLens) and femtosecond-assisted lenticular surgery (ie, LenSx and OptiMedica). This is where our field is going and all three are potential major advantages in our quest for refractive precision and happy patients.

– Randall J. Olson, MD
OSN Cataract Surgery Board Member