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PhacoXcap: A New Procedure Makes it Possible to Phaco Both Nucleus and Cortex Outside the Capsular Bag

Medisurg Research and Manage-ment Corporation has unveiled a new phaco technique, called PhacoXcap, that takes advantage of the unique cutting capabilities of the Fugo Blade (a.k.a. the plasma blade). The Fugo Blade generates a 50-micron plasma cloud around a tiny loop of wire at the end of a handpiece. The plasma cloud literally disintegrates tissue, making the Fugo Blade a unique and powerful cutting tool.

The new technique allows a surgeon to move both the cortex and nucleus outside of the capsule for phacoing in the iris plane. The entire procedure can still be performed through a 2.8-mm corneal incision.

What makes this possible is the Fugo Blade's ability to create a safe, large capsulotomy (about 8 mm in diameter) that doesn't tear. Unlike a "capsulorhexis" -- where the name implies tearing of tissue -- a Fugo Blade capsulotomy incision is made by tissue disintegration. As a result, Fugo Blade incisions don't spontaneously continue to tear. (Microscopic examination of the edge of an incision shows that it has a round contour, not the acute angle usually seen in a tear.)

Once the large opening has been made, it's easy to remove the entire cataractous lens and perform phaco in the iris plane. (The large opening also eliminates the problem of capsule entrapment syndrome.)

Here's how the procedure works:

• First, the surgeon performs a large Fugo Blade capsulotomy, leaving a 2-mm rim on the anterior capsule. (For more information about making a Fugo Blade capsulotomy, see "Plasma Capsulotomy" in the August 2001 issue of Ophthalmology Management.) The 2-mm rim provides stability for the lens zonules and allows stable placement of lens haptics.
• After making the capsulotomy, the surgeon gently injects balanced salt solution between the lens capsule and the cortex, forming a cleavage plane.
• Next, the surgeon imbeds the phaco tip into the nucleus and gently rocks the cataractous bulk back and forth. (See images, below.) Using the phaco tip, the surgeon rotates and lifts the entire mass of cataractous lens material out of the lens bag in one piece.
• Once the bulk of the lens is in the anterior chamber, the surgeon can gently push part of the bulk backwards through the pupil so that it holds the capsule back. (This helps to prevent the capsule from moving if the pressure fluctuates as a result of irrigation and aspiration during phaco.) The surgeon then phacos the cortex and nucleus at the iris plane, at a safe distance from the corneal endothelium and the lens capsule. This greatly reduces the risk of tearing the posterior capsule and losing vitreous.

Benefits of this new technique include increased surgical speed, greater control, and a reduced risk of complications. It also makes difficult cases much easier to manage:

• Mature cataracts are more manageable because you don't need a red reflex when creating a capsulotomy using the Fugo Blade.
• Working through a small pupil is easier because the Fugo Blade can safely be used underneath the rim of the iris, out of view of the surgeon, when making the capsulotomy (see image #1, below).

An instructional video is available from Medisurg Research and Management Corporation. For more information, call (610) 277-3937.

1. An 8-mm Fugo Blade capsulotomy being completed. The tip of the blade is under the upper left portion of the iris, incising capsule out of view of the surgeon.	2. Following capsulotomy and hydrodissection, the cataract is impaled with the phaco tip.	3. After rocking the bulk several times, it's lifted intact out of the lens bag.	4. The cloudy nucleus and cortex are phacoemulsified in the anterior chamber at the iris plane.