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Smaller coaxial tip may be alternative to bimanual phaco
The tip, with a reduced-diameter sleeve, allowed more fluid inflow than a separate irrigating instrument.
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A number of surgeons have recently embraced a bimanual phaco technique in order to take advantage of the smaller incision sizes that the sleeveless technique allows. Many surgeons, however, are hesitant to abandon the techniques they have grown familiar with using conventional, sleeved coaxial phaco tips.
A soon-to-be-available option for these surgeons may be a smaller, sleeved 2-mm coaxial used in combination with Flared tip designs that will allow the use of conventional technique through a smaller incision. At a recent meeting, two surgeons discussed their preliminary experiences with this device, the Ultrasleeve, which they used on the Alcon Infinti phacoemulsifier.
Donald N. Serafano, MD, and Khiun Tjia, MD, made separate presentations on their respective studies of the smaller sleeves, used in incisions of approximately 2 mm, at the American Society of Cataract and Refractive Surgery meeting in Washington.
“There is definitely an international trend toward smaller incisions in cataract surgery, and currently that means bimanual phaco,” Dr. Tjia said. “The drawback of using bimanual phaco that I find the most troubling is wound distortion and stretching by the rigid instruments.” Wound distortion leads to cumbersome wound closure and the need to use stromal hydration routinely, as well as a possible increased risk of endophthalmitis, he said.
In addition, current IOLs that would be appropriate for microincision cataract surgery (MICS) do not have a long-term track record, Dr. Tjia said. This means the microincision must be enlarged to accommodate conventional foldable IOLs, he said. Also, the bimanual technique involves a learning curve for most surgeons.
In a study to evaluate the smaller tip, Dr. Tjia said he found that it is possible to conduct efficient coaxial phacoemulsification surgery using the Ultrasleeve through an incision of 2 mm to 2.5 mm. The smaller tip offers the possibility to perform micro-coaxial without the current drawbacks of bimanual phaco, he said.
“When manipulating a sleeved phaco tip, the flexibility of the sleeve will prevent undue stress to the wound, which can be observed during bare metal tip movements in current bimanual emulsification,” Dr. Tjia said.
Using the Ultrasleeve through an incision of 2 mm to 2.5 mm, Dr. Tjia found that irrigation flow was reduced by 30% to 35% compared to a standard coaxial phaco tip. Other than this reduction, he said, his technique with the Ultrasleeve was “identical to standard coaxial phacoemulsification.”
To use the Ultrasleeve, Dr. Tjia optimized the fluidics parameters on the Alcon Infiniti to allow cataract removal through the microincision. Settings included a bottle height of 90 cm, an aspiration rate of 30 mL/min (normally 45 mL/min) and a vacuum of 400 mm Hg (normally 450 mm Hg).
Dr. Tjia said he inserted a standard Alcon AcrySof 6-mm-optic IOL using the Monarch II injector through the 2-mm incision.
“The final incision size, because it stretches, is 2.1 mm,” he said. “The good news is there is no stromal hydration necessary, and you do not induce significant wound stretching. I think this will drive our phacoemulsification in this direction. … With a 6-mm optic you can get safe and watertight 2-mm incisions.”
Smaller phaco tip sleeves
In his presentation, Dr. Serafano also noted the “new frontier” of trying to reduce incision size from the standard 3-mm phaco incision.
“Some people are doing this with bimanual sleeveless surgery, but I prefer to work on coaxial phaco in reducing the incision size,” Dr. Serafano said.
In a laboratory setting Dr. Serafano evaluated the occlusion-break response with several configurations: with infusion through commercially available irrigating forceps, through a coaxial microtip with the Ultrasleeve and through a standard coaxial phaco tip.
He found that the standard infusion sleeve provided the best response, but it required a 2.8-mm incision. The micro sleeve was able to be used in a 2.2-mm incision and provided a reduction in surge intensity and a more stable chamber when compared to the bare tip bimanual configuration.
“First we looked at flow rates, and the best flow is in the microtip with a standard sleeve. Second was flared tip with ultra-sleeve,” he said. “It turned out that the flared microtip with ultra-sleeve measured the smallest amount of surge intensity, but the coaxials in general obviously did better than the bimanuals.”
Dr. Serafano said the two biggest problems with a bimanual sleeveless phaco technique are the investment required in hand-held instruments and the change in technique.
“The new microsleeve is a viable and preferred method to conduct microincisional surgery,” Dr. Serafano said. “I think this is a viable way of stepping down the incision size and remaining coaxial without changing the surgical technique.”
For Your Information:
- Donald N. Serafano, MD, can be reached at 10861 Cherry St., Suite 204, Los Alamitos, CA 90720; 562-598-3160; fax: 562-598-7383; e-mail: serafano@gte.net. Dr. Serafano is a paid consultant to Alcon and has a grant as a clincial investigator.
- Khiun Tjia, MD, can be reached at Isala Klinieken, Locatie Weezenlanden, Groot Weezenlanden 20, 8011 JW, Zwolle, Netherlands; 31-38-424-2980; fax: 31-38-424-3334; e-mail: k.tjia@isala.nl. Dr. Tjia is a research consultant for Alcon.
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.