Phaco systems and instruments offer versatility, increase patient satisfaction

Three prominent surgeons discuss major phaco platforms and some of the hand-held instruments used with those systems.

Eric D. Donnenfeld

Evolving phacoemulsification platforms offer versatile and precise power-modulated ultrasound, vacuum and fluidics. Various hand-held instruments used in conjunction with those platforms help surgeons perform cataract surgery with safety and accuracy.

In telephone interviews with Ocular Surgery News, OSN Cornea/External Disease Section Editor Eric D. Donnenfeld, MD, FACS, and surgeons Mark Packer, MD, and Y. Ralph Chu, MD, described their preferred phaco platforms and associated instrumentation.

The experts discussed three major phaco platforms — the WhiteStar Signature System (Advanced Medical Optics), the Infiniti Vision System (Alcon) and the Stellaris Vision Enhancement System (Bausch & Lomb) — and the various instruments that can be used with them.

“The bottom line is, all three of these phaco units are really terrific, and there are significant advantages over previous technology,” Dr. Donnenfeld said. “As we enter into an era where patients’ demands are becoming more significant, I am convinced that we see clearer corneas the next day, with less endothelial cell loss and better results from every perspective.”

Dr. Chu said that all three phaco platforms have evolved over the years.

“I think all the systems represent a pretty significant step forward from their previous generation models,” he said.

Vacuum

Dr. Packer said the Stellaris platform features the Stable Chamber fluidics system with vacuum aspiration. The venturi pump is more responsive than a peristaltic pump because it offers surgeon controlled constant vacuum at the tip.

Mark Packer

“It’s a very efficient system, especially with softer degrees of cataract, softer lenses, which we have been doing increasingly,” Dr. Packer said. “It’s very efficient and very safe if you know how to use it.”

Fusion Fluidics, a software package included with the WhiteStar Signature, maximizes chamber stability, Dr. Donnenfeld said.

With Fusion Fluidics, a surgeon can switch between venturi and peristaltic vacuum on the fly to maximize chamber stability. The variable duty cycle lets the surgeon apply maximum phaco energy while avoiding complications, Dr. Donnenfeld said.

“Less phaco energy in the eye means fewer phaco complications,” he said.

Regarding the dual pump system, Dr. Chu said, “You get the safety and the control of the peristaltic system, and you get the speed, efficiency and good cortical cleanup with the venturi system.”

Handpieces

Hand-held instruments are used with one or more modes of ultrasound, vacuum and fluidics. For example, the OZil Torsional handpiece (Alcon) may be used with longitudinal or torsional ultrasound.

“The idea behind OZil is that you can break up material without a repulsive force,” Dr. Packer said. “What I’ll do is use the longitudinal or traditional ultrasound for impaling the lens and holding it while I chop it into pieces. Then, I’ll switch to torsional and emulsify and extract these quadrants or pie-shaped pieces of nucleus. It’s very efficient. The torsional is great.”

The WhiteStar Signature handpiece offers transverse motion with a jackhammer effect for maximum cutting, Dr. Donnenfeld said.

“This takes that advance one step further and allows you to take advantage of the transverse motion of the phaco while continuing the jackhammer effect of a traditional phaco needle, so that you’re moving side-to-side and in-and-out at the same time and you’re getting the most efficient cut that you can get into the nucleus,” Dr. Donnenfeld said.

The Stellaris handpiece offers increased stroke length for efficient cutting and tight control of ultrasound application, Dr. Packer said. The instrument has six crystals that generate mechanical energy; most phaco handpieces have four crystals, he said.

Phaco tips

A Kelman-style or angled phaco needle, which is bent at the tip, is essential to obtain the side-to-side shearing motion of torsional phaco. However, Dr. Packer described the 30° bend in the traditional Kelman tip as “a little aggressive.” His said his colleague, OSN Cataract Surgery Section Member I. Howard Fine, MD, devised a tip with a 15° bend. In addition, Robert H. Osher, MD, designed an OZil 12 needle with a 12° angle that allows efficient torsional movement.

“I like these tips that have a shallower bend because it’s just easier for me to control where the tip actually is,” he said. “It’s more intuitive than those Kelman tips with the big bend in them.”

Dr. Packer also noted the differences of the OZil Reverse Kelman tip.

“The reason that it’s reversed is that the bevel is also moved to the other side,” Dr. Packer said. “So where in a traditional Kelman tip, the bevel is on the convex side of the bend, in this the bevel is actually turned toward the concave side, so it’s more natural for the type of chopping technique that I use.”

Dr. Chu helped devise the Chu chisel (Mastel), a modified phaco tip with four squared-off edges.

“The chisel helps in all situations, from soft, moderate to dense nuclei,” Dr. Chu said. “It’s really designed to help moderate to dense nuclei in terms of improving efficiency of the cutting, reducing phaco energy and helping more efficient removal of the nuclear cataract material.”

The Chu chisel may be used in conjunction with the Dewey Radius phaco tip (MicroSurgical Technology), which is more rounded. Its tip is straight, not bent, Dr. Chu said.

“The Dewey tip is designed to be protective of the posterior capsule if that were to get trapped in the phaco tip,” Dr. Chu said.

The Chu chisel is suited to transversal or longitudinal ultrasound, he said.

“I have used the Dewey tip, which is a nice tip that has a very soft sleeve, so it reduces your risk of rupturing the capsule during phacoemulsification,” Dr. Donnenfeld said. “I’ve also tried [the Chu chisel], which is a very strong, sharp phaco tip for very hard nuclei. It really cuts through the very hard nuclei very effectively.”

Other tools

Other tools can help make cataract surgery safer and more efficient. For example, Dr. Packer said the Fine-Hoffman Capsulorrhexis Forceps (MicroSurgical Technology) can be used through a paracentesis-sized 1.2-mm or 1-mm microincision.

“The great thing about that is, No. 1, that with the tiny incision and the eye filled with viscoelastic, the chamber is incredibly stable while you make your capsulorrhexis,” Dr. Packer said. “With today’s accommodating lenses and multifocal lenses, it’s really important to get the capsulorrhexis just the right size. This really allows that because there’s no shallowing of the chamber as you’re making your tear.”

The Seibel Rhexis ruler (MicroSurgical Technology) helps the surgeon make precise capsulorrhexis measurements, Dr. Packer said. The ruler has markings that enable the surgeon to accurately visualize the capsulorrhexis size.

“Another new method of sizing the capsulorrhexis has been developed by Carl Zeiss Meditec; it is a circular image with an eye tracker that adjusts for the magnification of the cornea, and you can actually sort of tear along the dotted line,” Dr. Packer said.

Dr. Chu described the Chu LRI marker (Katena), which he helped design for limbal relaxing incisions. The marker does not use ink, which can obscure the incision site. Rather, the device creates indented hash marks in the epithelium that mark the axis and incision length.

In addition, Drs. Donnenfeld and Packer spoke favorably of the wireless foot pedals available on the WhiteStar Signature and Stellaris platforms, with Dr. Packer noting the benefit of having fewer wires cluttering the operating room.

For more information:

Y. Ralph Chu, MD, can be reached at Chu Vision Institute, 9117 Lyndale Ave. South, Bloomington, MN 55420; 952-835-0965; fax: 952-835-1092; e-mail: yrchu@chuvision.com. Dr. Chu receives grant/research from Advanced Medical Optics and is a consultant for Advanced Medical Optics and Bausch & Lomb.

Eric D. Donnenfeld, MD, FACS, can be reached at Ophthalmic Consultants of Long Island, 2000 North Village Ave., Rockville Centre, NY 11570; 516-766-2519; fax: 516-766-3714; e-mail: eddoph@aol.com. Dr. Donnenfeld is a consultant for Advanced Medical Optics, Alcon and Bausch & Lomb.

Mark Packer, MD, can be reached at Drs. Fine, Hoffman and Packer, LLC, 1550 Oak St., Suite 5, Eugene, OR 97401; 541-687-2110; fax: 541-484-3883; e-mail: mpacker@finemd.com. Dr. Packer is a consultant for Advanced Medical Optics, Bausch & Lomb and Carl Zeiss Meditec. He receives honoraria from Alcon

Advanced Medical Optics can be reached at 1700 E. St. Andrew Place, Santa Ana, CA 92705; 714-247-8200; fax: 714-247-8672; Web site: www.amo-inc.com. Alcon can be reached at 6201 South Freeway, Fort Worth, TX 76134; 817-293-0450; fax: 817-568-6142; Web site: www.alconlabs.com.

Bausch & Lomb Surgical can be reached at 180 Via Verde, San Dimas, CA 91773; 800-338-2020; fax: 800-362-7006; Web site: www.bausch.com.

Carl Zeiss Meditec can be reached at 5160 Hacienda Drive, Dublin, CA 94568; 925-557-4100; fax: 925-557-4101; Web site: www.zeiss.com.

Katena Products can be reached at 4 Stewart Court, Denville, NJ 07834; 973-989-1600; fax: 973-989-8175; Web site: www.katena.com.

Mastel can be reached at 2843 Samco Road, Suite A, Rapid City, SD 57702; 605-341-4595; fax: 605-343-3631; Web site: www.mastel.com.

MicroSurgical Technology can be reached at 8415 154th Ave. NE, Redmond, WA 98052; 888-279-3323; fax: 425-556-0437; Web site: www.microsurgical.com.

Matt Hasson is an OSN Staff Writer who covers all aspects of ophthalmology. He focuses on regulatory, legislative and practice management topics.