The right tools can make cataract surgery more efficient

A surgeon explains his phaco technique, which uses two ophthalmic viscoelastic devices and a two-pump phaco system.

Introduction

Thomas John

Modern-day phacoemulsification techniques provide smaller surgical wounds, induce no surgical astigmatism, eliminate sutures, and culminate in shorter surgical times and improved quality of vision after surgery. However, protection of the corneal endothelium and iris, especially in floppy iris syndrome and in small pupil cases, is of paramount interest to the ophthalmic surgeon.

In this column, Dr. James Loden describes his technique of combined use of cohesive Healon and dispersive and cohesive Healon 5 along with a two-pump phaco system, namely, a venturi pump and a peristaltic pump, that he alternates as needed during the phacoemulsification procedure.

– Thomas John, MD
OSN Surgical Maneuvers Editor

James C. Loden

The technique I use involves a combination of Healon (sodium hyaluronate, Abbott Medical Optics) and Healon 5 (sodium hyaluronate 2.3%, AMO) that I believe creates the ideal environment for phacoemulsification.

A paracentesis port is first made before the corneal incision. After the local anesthetic is instilled, Healon 5 is injected into the anterior one-third of the anterior chamber, filling it approximately two-thirds full. Next, the cannula attached to the syringe containing regular Healon is placed on the anterior capsule in the center of the pupil, and the anterior chamber is filled until the globe is firm. The regular Healon compresses the Healon 5 against the cornea. Healon 5 is a super-viscous substance that provides superior corneal endothelial protection, while its dispersive quality allows it to be well-retained and to maintain space in the eye during high shear manipulations.

The drawback of using only Healon 5 is that its super-viscous nature can impede the capsulorrhexis. The combination of Healon 5 with regular Healon on top of the anterior lens capsule permits capsulorrhexis to be performed with the same speed and agility that I prefer, without risking displacement or tracking of the capsule that can occur with Healon 5 alone. The staying power of Healon 5 is clearly visible during surgery. If the handpiece emits small bubbles during insertion, these air pockets trapped in place in the viscoelastic layer will be visible during phacoemulsification. This gives me confidence that the Healon 5 maintains its location and continues to protect the corneal endothelial layer and that is has not slipped out of the eye with the insertion of the phaco handpiece, as often occurs with regular Healon.

Venturi and peristaltic phaco

I use the WhiteStar Signature System with the Ellips handpiece (AMO) and have found that the Ellips handpiece allows me great followability. Once the nucleus has been chopped, I switch to high vacuum/high flow venturi phaco. With venturi, I keep my phaco tip still, in the center of the pupil at the iris plane, and allow the fluidics and my chopper to bring the pre-chopped segments to the phaco tip. With Ellips, I have found the energy delivery (simultaneous transversal and ultrasound) to be the perfect blend, even on hard nuclei, and I have not experienced any clogging of the phaco handpiece or tubing. Because the handpiece does not clog, I have not had any sudden occlusion surges or thermal issues. I have experienced excellent success, with great anterior chamber stability and very high vacuum and flow rates, and no problems with either capsular stability or post-occlusion surge.

After the temporal corneal incision is created, I use a stop-and-chop technique in which I create a groove using standard peristaltic phacoemulsification. Then I move to position 2 with a very high- powered venturi aspiration and remove the segments that have been previously grooved and chopped. Before using the WhiteStar system, I had been using only peristaltic phacoemulsification, but I always enjoyed using a venturi pump due to the speed at which things move in the anterior chamber. Signature gives me the ability to switch between the two pump systems during surgery, enabling me an average total procedure time of 7 minutes, with many cases being as quick as 4 minutes.

Healon 5 is injected into the anterior third of the anterior chamber, filling it approximately two-thirds full.

The cannula is placed on the anterior capsule in the center of the pupil and fills the anterior chamber with Healon until the globe is firm, compressing the Healon 5 against the cornea, away from the capsule. Images: Loden JC

Bubbles in the anterior chamber remain trapped in the Healon 5 throughout, signaling that the viscoelastic remains in place.

The phaco tip remains in the center of the pupil, in the iris plane, allowing the fluidics and chopper to deliver the pre-chopped segments to the tip.

I have performed more than 300 cases using the Healon/Healon 5 combination with great success. There has been no persistent postoperative corneal edema even with grade 3+ and 4+ cataracts. The results show good corneal clarity on the first postoperative day. I have experienced only trace corneal edema on postoperative day 1, and the edema cleared in all patients by 1 week after surgery. Approximately 10% of my patients are on alpha-blockers such as Flomax (tamsulosin, Boehringer Ingelheim), creating the risk of intraoperative floppy iris syndrome (IFIS). Even in these at-risk patients, we are able to remove the cataract without any iris retraction hooks or Malyugin rings (MicroSurgical Technology) in 90% of cases.

Healon 5 appears to be very good for viscodilating the pupil, allowing the surgeon to obtain a good capsulorrhexis and hydrodissection in IFIS cases. Once a good capsulorrhexis is achieved, I can cut a groove and break the nucleus into two pieces, and then I am able to do a blind chop technique up under the border of the iris, if needed. Then I take the loose segments that I have chopped and bring them into the pupil with my Connor wand (Rhein), where they are phacoemulsified. A 3- to 4-mm pupil allows me to comfortably complete the case.

IFIS cases, small pupil cases

I feel comfortable maintaining my high flow/high vacuum venturi settings on IFIS patients. The high settings on the WhiteStar Signature System have worked well on IFIS cases because I can surge the linear control with the foot pedal and decrease flow in the vacuum until there is occlusion of the nuclear segment. Holding the handpiece stationary and away from the iris, cornea and capsule while I use the foot pedal allows me to emulsify the segment mid-pupil, while the fluidics of the machine prevent the iris or posterior capsule from coming up into the phaco tip. With the sidekick of my Signature phaco foot pedal, I can switch from phaco 2 with venturi high vacuum/high flow to phaco 4 peristaltic medium vacuum/low flow. The great advantage of the WhiteStar is that it gives the surgeon choices.

In cases with small pupils, I will use the Bechert nucleus rotator (ASICO) or a Kuglen hook (Katena) to manually retract the iris border when performing irrigation and aspiration. The residual Healon then serves to viscodilate the pupil and fill the capsular bag, allowing for IOL insertion. The Healon is easy to remove at the end of the surgery due to its cohesive viscoelastic properties, without concern about entrapment of any material under the small pupils of IFIS cases.

Since my practice has started using the WhiteStar system with Ellips and Healon, I feel that I have improved my efficiency and optimized outcomes as an ophthalmic surgeon. I am able to operate more comfortably and provide my cataract patients with a higher quality of service.

• James C. Loden, MD, can be reached at Loden Vision Centers, 907 Rivergate Parkway, Suite C2020, Goodlettsville, TN 97072; 615-859-3937; fax: 615-859-3941; e-mail: lodenmd@lodenvision.com. Dr. Loden is a consultant for AMO.