Phaco technologies minimize complications, enhance visual outcomes

Versatile vacuum and fluidics, phaco tips, and choppers enable surgeons to optimize visual outcomes and minimize risk for patients undergoing phacoemulsification. Varied incision designs and surgical techniques also play a key role in boosting safety and outcomes.

Bonnie An Henderson, MD, OSN Cataract Surgery Board Member, said improvements to established phacoemulsification platforms have enhanced surgical safety and efficacy.

“The newer phacoemulsification systems, regardless of the manufacturer, have made great advances in improving the safety and efficiency of the surgery,” Dr. Henderson said in an interview with Ocular Surgery News. “I think that those improvements on the phaco platforms have really allowed for better clinical outcomes for the patients.”

Phaco platforms and accessories

Dr. Henderson said she uses Alcon’s Infiniti Vision System with a peristaltic pump and Bausch + Lomb’s Millennium platform with a venturi pump. The Millennium also has peristaltic capability.

“Our surgical centers have both systems, so I have the fortunate ability of being able to use both. I think each of the systems has different strengths,” Dr. Henderson said.

The OZil torsional handpiece (Alcon) affords the ability to dissect dense cataracts with minimal phaco energy, she said.

Originally, the OZil came with a Kelman tip bent at a 30° angle. However, adapting to the bend can be challenging.

“Some surgeons who have not used an angled tip worry that they may accidentally rupture the posterior capsule,” she said. “However, this is not common, and the learning curve of using an angled tip is short.”

Currently, the company offers a tip with a bend of about 12°, along with various flared, non-flared, tapered and non-tapered tips to accommodate a range of chopping techniques.

Alcon is preparing to launch the Ultrachopper, an ultrasonic blade designed for use with the Infiniti platform.

“The Ultrachopper is a unique instrument because it uses the power of the ultrasound to deliver precise cutting of the lens,” Dr. Henderson said.

Mark Packer, MD, said he prefers the Signature phaco platform (Abbott Medical Optics) with venturi and peristaltic pumps. Dr. Packer uses the venturi setting in most cases except those involving floppy iris syndrome.

“I use a vertical chop technique, a direct chopping technique, so I have an initial setting where I’ve got higher vacuum for holding the material as I chop it up,” he said. “For segment removal, I’ve got a little lower vacuum and a little more power to emulsify and aspirate material.”

Dr. Packer uses the Ellips handpiece with transversal ultrasound (AMO) and a 30° 20-gauge straight phaco needle (MicroSurgical Technologies).

“It’s very similar in its effect to what OZil does with the Infiniti, but you don’t need to use a Kelman tip and you don’t need the bent tip,” Dr. Packer said.

The Ellips handpiece offers efficiency in collecting lens fragments, Dr. Packer said.

“The Ellips is nice because there’s better followability,” he said. “There’s less material flying around the chamber.”

Microcoaxial, biaxial approaches

Dr. Henderson said she favors a microcoaxial approach through a 2.2-mm incision.

“I prefer a smaller incision size because it decreases the amount of induced astigmatism,” Dr. Henderson said. “A 2.2-mm incision is large enough to use coaxial technology, which I prefer, yet it’s small enough to prevent significant flattening of the meridian.”

The bimanual or biaxial approach involves a relatively large side-port incision that can be prone to leakage, Dr. Henderson said.

“When you use a bimanual approach, the second incision is a little bit larger than your typical side-port incision that you use with a coaxial approach. The side-port incision can sometimes be stretched with the rounded irrigation probe and can leak,” she said.

Dr. Packer said he prefers the biaxial approach.

“I’m a biaxial surgeon,” Dr. Packer said. “I actually prefer the term bimanual, although I know in terms of strict lexicography it’s not as accurate.”

The biaxial approach involves separate ports for infusion and aspiration.

“That’s the key to it,” Dr. Packer said. “What I find advantageous about it is that you’ve got your irrigation and your aspiration from a separate location. So, you don’t have outflow and inflow competing with each other and creating turbulence and other issues. It makes the surgery more adaptable and more efficient.”

Femtosecond lasers add precision

Six companies, Abbott Medical Optics, Alcon/LenSx, Carl Zeiss Meditec, LensAR, OptiMedica and Technolas, are in various stages of development and approval regarding dedicated femtosecond laser systems for cataract surgery.

Femtosecond lasers enable surgeons to create self-sealing incisions and use less ultrasound energy for lens fragmentation, reducing damage to the lens capsule, zonules and corneal endothelium, Dr. Packer said. – by Matt Hasson

• 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.
• 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.
• Disclosures: Dr. Henderson is a consultant for Alcon. Dr. Packer is a consultant for Abbott Medical Optics, Bausch + Lomb and LensAR.