Hot on the Trail of Cold Phaco
Tips for adopting these new technologies and a look at where they'll take cataract surgery.
Compiled by Ophthalmology Management staff

Cataract surgery may never see another advance as big as ultrasound phacoemulsification, but several new tools, available now or in the near future, offer you the means to incrementally improve your phaco procedures by enhancing their safety and efficiency. These new "cold" phaco technologies also open the door for
1-mm-incision procedures.

We questioned five surgeons about some of these new tools. They shared their experiences with efficiency, safety and learning curves, offered pearls, and commented on the future of cataract/implant surgery.

Dr. Harry Grabow on SonicWave
OM: Has the SonicWave (STAAR) improved the efficiency of your phaco procedures?

Dr. Grabow: In the past, our average turnover rate was approximately 5 cases per hour. We're now performing slightly more than 6 cases per hour, which we attribute to several factors.

One factor is that we've simplified the incision process to semi-simultaneous clear-cornea incisions. With this technique, we make the sideport and primary phaco incisions in less than 10 seconds. Second, we've combined the injection of viscoelastic with the initial bent-needle capsulotomy by placing the bent 25-gauge needle on the viscoelastic syringe.

Third, we have two operating rooms and two STAAR SonicWave phaco systems with Gravlee Safety Bevel tips. We've observed two improved functions. The Gravlee tip, because of its sharp, internal orifice, improves nuclear holdability and reduces nuclear-tip purchase time. And the sonic mode, which reduces tip frequency to 40 to 400 cycles per second, greatly improves holdability and reduces the chatter that we often see with ultrasonic frequencies. I currently use the sonic mode in 60% to 70% of cases, not in 3+ and 4+ nuclei.

OM: How steep is the learning curve?

Dr. Grabow: The sonic mode requires virtually no learning curve. The surgeon activates the foot pedal to alternate between the sonic and ultrasonic modes.

The Gravlee Safety Bevel tip, because of its extremely efficient holding and cutting power, has a small learning curve, particularly with very soft nuclei. If you're accustomed to rapid and deep sculpting of firm nuclei with significant foot pedal pressure in position 3, using the Gravlee tip in that fashion in a very soft nucleus could result in immediate aspiration through the nucleus and posterior capsule.

OM: Can you share a few pearls about using the SonicWave most effectively?

Dr. Grabow: I find it useful to begin most cases in ultrasonic mode because I'm using a four-quadrant chopping technique. I use ultrasonic mode to initially bury the phaco tip to engage the nucleus for the first chopping bisection. I then rotate the two heminuclei 90 degrees and, maintaining ultrasonic frequency, bury the tip in the distal heminucleus and chop it into two quadrants. At this point, the technician raises the vacuum from 100 to 220, and I convert the handpiece frequency from ultrasound to sonic. I then maintain sonic mode for quadrant and epinucleus removal.

OM: Realistically, what further advances in phacoemulsification would you like to see?

Dr. Grabow: The big interest now is in "cold" phaco 1-mm-incision surgery. Several systems are now available that are capable of safe, unsleeved phacoemulsification. The STAAR sonic machine is one; others include the Allergan Sovereign with WhiteStar and the Alcon Legacy with NeoSoniX. Because the metal phaco tip doesn't produce heat with these systems, cold coaxial irrigation is unnecessary. Therefore, the irrigating sleeve can be removed and emulsification can be performed with the unsleeved tip through incisions as small as 1 mm.

To maintain chamber volume, irrigation is provided through the sideport incision, usually with an irrigating chopper. This provides the additional advantage of improved nuclear holding ability compared with sleeved coaxial irrigation, which pushes nuclear fragments away from the phaco tip.

This new 1-mm cataract removal technology, however, is ahead of 1-mm cataract replacement technology. We've not yet developed IOLs that will be implantable through 1-mm incisions. However, investigators are beginning implantation with a rollable, acrylic IOL manufactured by ThinOptX.

Other cold cataract removal techniques in various stages of development that may enable 1-mm surgery include water-jet technology, plasma-blade technology and laser technology.

Dr. Brock Bakewell on WhiteStar
OM: Has WhiteStar technology (Allergan) improved the efficiency of your phaco procedures?

Dr. Bakewell: WhiteStar has improved the efficiency of my phaco procedures by cutting in half the total amount of ultrasound used. When ultrasound is applied to a cataract in the continuous mode, a redundant amount of energy is used. WhiteStar makes it possible to use millisecond pulses of ultrasound. Because less energy is used, the cornea experiences less trauma and this produces a clearer cornea the day after surgery.

Also, by using WhiteStar, it's impossible to produce a corneal burn. The phaco tip doesn't get hot like it does with phaco in a continuous ultrasound mode.

OM: How steep was the learning curve?

Dr. Bakewell: The learning curve is relatively flat. A surgeon doesn't have to modify his/her technique. WhiteStar works well with phaco-chop, divide-and-conquer, or phaco-flip techniques. It makes a surgeon's current technique better by applying less total ultrasound energy to the eye. The anterior chamber is also more stable when using WhiteStar compared with continuous-mode ultrasound. This equates to less trampolining of the posterior capsule and a higher level of safety.

OM: Can you share a few pearls for using WhiteStar most effectively?

Dr. Bakewell: If you're a divide-and-conquer surgeon, you may want to use a Kelman tip because it increases the efficiency of the cutting and further reduces ultrasound time. If you're using a divide-and-conquer technique on a 4+ nuclear sclerotic cataract, be patient when sculpting because the phaco tip may not move as swiftly through the cataractous tissue compared with continuous mode.

OM: Realistically speaking, what further advances in phacoemulsification would you like to see?

Dr. Bakewell: In terms of further advances in phacoemulsification, I think that there will be only small changes. The major advances have already occurred.

What will probably be routine in the future is bimanual phacoemulsification through two 1-mm stab incisions. WhiteStar enables this because the phaco needle doesn't produce heat, which means the irrigation sleeve can be removed from the phaco needle.

IOL technology needs to improve so that a lens can be injected through a 1-mm incision. In addition, lens technology will continue to improve so that the eye's optical system can improve (accommodative and prolate IOLs).

Also, it will be interesting to see whether laser phaco systems will improve to the point where they compete with ultrasound phaco.

Dr. Stephen Pascucci on laser cataract removal
OM: Has laser cataract removal (using the Dodick Laser Photolysis System from A.R.C. Laser) improved the efficiency of your phaco procedures?

Dr. Pascucci: I'm an efficient ultrasonic phaco surgeon already, so I didn't expect to see any significant increases in efficiency. However, I don't see increased efficiency as the major advantage to this technology.

I believe its advantages relate to its abilities to allow for successful cataract removals through very small incisions and avoid the effects to the cornea and incision that ultrasonic phaco causes. Indeed, I've observed that uniformly those eyes of patients who have undergone laser cataract removal are less inflamed in the initial postoperative days.

OM: How steep was the learning curve?

Dr. Pascucci: The learning curve is moderately steep. I believe that surgeons who routinely do "two-handed" phaco procedures and who are accustomed to phaco-chop procedures will have an easier time adopting this new technology than those who are "one-handed" phaco surgeons.

OM: Can you share a few pearls for using laser phaco most effectively?

Dr. Pascucci: The pearls I can offer would be to learn, first, to remove cataracts using a "two-handed" technique. An additional, and what I would consider a critical step, would be to perfect the pre-splitting of the lens nucleus through its entire thickness. If you don't achieve a clean, complete segmentation of the nucleus, the case will turn out to be much more difficult than it needs to be, and conversion to traditional ultrasonic phaco may be necessary. Simply put: Segment the lens with care, and take your time doing it.

OM: Realistically speaking, what further advances in phacoemulsification would you like to see?

Dr. Pascucci: I believe that as cataract removal can be accomplished through smaller and smaller incisions, IOLs that can be placed through these incisions must be perfected.

In other words, laser phaco technology has allowed for successful cataract removal through very small incisions. It's a highly efficient procedure and is characterized by minimal inflammation during the initial post-op period. IOL technology must now catch up with cataract removal technologies.

Dr. John Wright on laser cataract removal
OM: Has laser cataract removal (using the Photon system from Paradigm Medical) improved the efficiency of your phaco procedures?

Dr. Wright: Rather than added efficiency, the advantage of the system is that it is nearly impossible to rupture the posterior capsule with the laser.

OM: How steep was the learning curve?

Dr. Wright: Using the handpiece seems similar to aspirating a soft cataract by using an irrigation/aspiration tip only, but the laser assists in allowing the lens material to enter the aspiration port more efficiently.

OM: Can you share a few pearls for using laser phaco most effectively?

Dr. Wright: It's currently not effective on denser cataracts, but if I encounter a denser cataract, I can use a second instrument, such as a Bechert Nucleus Rotator, to assist in forcing the material into the aspiration port. Even more desirable is to switch to the ultrasound phaco handpiece that's built into the same system. Having everything in the same workstation is advantageous, and the fluidics on the phaco system itself are very desirable.

OM: Realistically speaking, what further advances in phacoemulsification would you like to see?

Dr. Wright: My feeling is that the laser phaco systems at this point are not in a position to replace traditional phaco, but are a nice adjunctive treatment, particularly with soft posterior subcapsular cataracts where there may be concerns about rupturing the posterior capsule. The system appears to be a step in the right direction, and I'm sure the technology will go through years of further refinements and improvement.

Dr. I. Howard Fine on NeoSoniX and AdvanTec
OM: Have the NeoSoniX handpiece and the AdvanTec software (Alcon) improved the efficiency of your phaco procedures?

Dr. Fine: NeoSoniX has improved the efficiency of my phaco procedures by a considerable amount. We've experienced approximately an 87% decrease in our effective phaco time and about a 57% decrease in our average phaco powers.

We've had an increase from about 70% to 98% of patients with uncorrected VA of 20/40 or better with the addition of NeoSoniX with AdvanTec software to the Legacy.

OM: How steep is the learning curve?

Dr. Fine: The learning curve is almost flat. This is a new technology that requires no change in technique, equipment, tips, tubing, etc., so one can transition to this at whatever rate they wish just by adding the NeoSoniX and playing with the different amplitudes and thresholds.

OM: Can you share a few pearls about using the NeoSoniX handpiece most effectively?

Dr. Fine: Yes, learn to chop and avoid divide-and-conquer.

OM: Realistically, what further advances in phacoemulsification would you like to see?

Dr. Fine: I'd like to see us be able to perforate the eye at the pars plana with a 30-gauge needle, go through the equator of the lens and perforate the capsule, inject a chemical agent to emulsify the lens using the same needle (attached to a two-way syringe), aspirate the lens contents, and then (again using the same needle, with a three-way stopcock) inject a flexible polymer to refill the capsular bag and preserve accommodation.