Enhancing Phaco
An update on some newly added, useful features.
Compiled by Christopher Kent, Senior Associate Editor

In addition to major developments such as "cold" phaco, today's phaco machines continue to evolve in smaller, yet significant ways. Every year manufacturers add innovations designed to enhance surgeon control and outcomes. We invited several companies to talk about their latest features and upgrades. Here's what's new.

Effective surge prevention

At this year's AAO meeting, STAAR Surgical plans to introduce a new device that helps resolve a traditional problem encountered during phacoemulsification: the surge that can occur when an occlusion at the tip finally breaks. The new device, called "Cruise Control" uses a specially designed filter to limit surge -- regardless of vacuum setting, the size of the phaco tip or the diameter of the tubing.

Under normal conditions, a standard 19-gauge phaco tip used with a vacuum setting of 400 mmHg could generate a surge as high as 300 cc/min. A smaller phaco tip produces less surge, but also reduces efficiency. Likewise, reducing tubing diameter can minimize the problem, but it increases the likelihood of stagnation and occlusions in the tubing.

The Cruise Control device (see diagram below) is a single-use cylindrical filter placed between the phaco handpiece and the aspiration tubing. It serves two purposes: First, a small orifice (the size of an I/A tip) leading from the filter to the aspiration line provides nonlinear flow restriction to limit vacuum surge. Second, the filter captures and retains all cataract material removed from the eye, keeping material from reaching the orifice. (The filter has a large surface area, so it doesn't clog.)

Because the fluid is forced through the narrow orifice, flow is prevented from rising above 50 cc/min. (See chart, above.) Meanwhile, regular flow below 40 cc/min remains unaffected. As a result, a surgeon can use a large phaco tip and work at high vacuum without endangering chamber stability. At the same time, the orifice can't be clogged because only clear fluid comes out of the filter. (The filter also keeps the inside of the tubing clean longer and prevents material from accumulating inside the machine itself.)

Mark Packer, M.D., who practices at Drs. Fine, Hoffman & Packer in Eugene, Ore., has had the Cruise Control filter for several months. "This is a simple, elegant idea," he observes. "It helps speed the procedure along because you don't have to worry as much about surge, and it has the advantage that it can be attached to the aspiration line of any phaco machine.

"This is something surgeons should consider using as an adjunct to their current phaco machines -- particularly surgeons who use high-vacuum techniques or reusable tubing. The filter should definitely help keep the tubing cleaner."

For more information about the Cruise Control filter, contact STAAR Surgical at (800) 292-7902, extension 2330.

Smoothing out the rough spots

Alcon is introducing two new phaco enhancements in 2002:

The silicone tip. A few months ago, Alcon unveiled a new irrigation/aspiration tip made of silicone. According to the company, a silicone I/A tip is both softer and smoother than a reusable metal tip, making it much more capsule-friendly. A metal tip can damage the capsule if it becomes sharp or develops a burr.

Surgeons using a metal tip often employ a stripping technique that involves aspirating material with the tip and then rolling the aspiration port upwards before evacuating the material, pointing it away from the posterior capsule. This technique prevents the posterior capsule from coming in contact with the metal tip, avoiding any possibility of tearing. Although this technique is effective, it makes surgery less efficient.

Because the new silicone tip is far less likely to tear the posterior capsule if they come in contact, you can keep the port aimed toward the cortex you're trying to aspirate and remove it in larger pieces. In fact, many surgeons have found that the silicone tip makes it possible to "unzip" the cortex and take it off in much larger pieces -- in some cases, a single piece. This technique is both safer for the zonules and more efficient.

Leslie Grosinger, M.D., who practices in Bloomfield Hills, Mich., has been using the silicone I/A tip for the last year. "I find it very capsule-friendly, much more so than traditional technology," he says. "I can be more aggressive in stripping cortex because it's considerably safer, as well as faster and more efficient. It also allows me to polish the capsule safely, without the use of additional instrumentation.

"I use it exclusively now," he adds. "I much prefer it to older technology."

The silicone tip can be reused a limited number of times, and it's designed to work with any phaco system.

The new silicone I/A tips from Alcon are less likely to cause a tear if they come in contact with the posterior capsule.

A smoother sleeve. This fall, Alcon will debut the MicroSmooth Sleeve -- a new irrigation sleeve designed to reduce friction and eliminate binding when inserting the tip. Using the MicroSmooth Sleeve, the phaco needle glides more freely in and out of the wound, giving the surgeon greater control. Alcon reports that surgeons trying the new sleeve have called it "a subtle difference that you get hooked on." (Unlike the silicone I/A tip, the MicroSmooth sleeve works only with Alcon's LEGACY System.)

Dr. Robert J. Cionni, M.D., medical director at the Cincinnati Eye Institute, has used the MicroSmooth Sleeve and finds it to be a big plus during surgery. "The MicroSmooth Sleeve is wonderful," he says. "It has two significant advantages: First, because its outer walls are very smooth, you can make a tighter incisional seal so you don't get fluid egress, yet your phaco tip still glides easily without distorting the wound or causing excessive movement of the globe. Second, using a MicroSmooth high-infusion sleeve, I can keep the bottle height low and deliver a larger volume of infusion fluid at a lower pressure with less turbulence.

"These advantages make a tremendous difference."

To get more information about Alcon's new silicone I/A tip, or the MicroSmooth Sleeve for the LEGACY System, call (800) TO-ALCON.

Remote control goes wireless

American Optisurgical Inc., which manufactures the Horizon phaco system, has recently begun offering a new remote control system for the Horizon that allows a Palm Pilot wireless handheld device to control the phaco unit. The Palm Pilot then functions the same way a wired remote control would -- but it adds a host of new options and capabilities. (The software works with any Palm Pilot.)

Among the advantages of this system:

• The surgeon can use his own personal Palm Pilot, with his own settings in memory, as the controller. When the surgery is completed, the surgeon takes his Palm Pilot with him, eliminating the possibility of anyone else altering parameters or settings.
• If you already own a Palm Pilot, you won't need to purchase a new piece of equipment.
• Each surgeon can link the phaco system to his or her own personal Palm Pilot, complete with unique parameter settings, and be ready to operate.
• Because the Palm Pilot is lightweight and wireless, the controller can be kept anyplace that's convenient during surgery: in a pocket, on a table, in a bag, etc.
• You can also use this controller as a personal computer: taking notes, checking your schedule, using it as an automatic reminder, and so forth.
• You can use the Palm Pilot/controller to download settings from another doctor or to share your own settings with another surgeon.
• A distributor can download new features directly into the Palm Pilot.
• You can reorder surgical parts directly using the Palm Pilot, as needed.

	The Horizon phaco system from American Optisurgical Inc. can now be controlled using a Palm Pilot, adding multiple options and capabilities.

Although the software will work with any Palm Pilot, it's designed to control only the Horizon phaco system.

Cam Cameron, president of American Optisurgical Inc., explains that the Horizon phaco system was originally designed for use in emerging countries, so it's small and weighs only about 22 pounds. Nevertheless, it offers most of the same features competing systems offer, including programmable software, a large control touchpanel, a programmable footpedal, burst control, multiple (customizable) preset programs for phaco, noninvasive vacuum sensing, the option of reusable or disposable tubing, a very efficient phaco driver and a small handpiece. (The Horizon phaco system currently sells for about $17,000.)

For more information about the Horizon phaco system or the Palm Pilot-based remote control, contact American Optisurgical at (800) 576-1266 (United States only), via e-mail at info@optisurgical.com, or by visiting the Web site at www.optisurgical.com.

Tracking parameters onscreen

Bausch & Lomb has announced the availability of a new Video Overlay system designed to be used with the Millennium phaco system. When surgery is being monitored or recorded by a video camera, the Video Overlay system (a separate box that's attached to the Millennium) displays the changing surgical parameters onscreen, overlaid on the surgical images. Seeing the changing parameters in real time makes the video far more valuable as a source of information.

This should be a powerful tool for any surgeon who gives presentations or teaches. It's also an excellent way to document a special case or to review your technique.

For more information about the new Video Overlay system, contact Bausch & Lomb by calling (800) 531-2020, or by visiting the Web site at www.bausch.com.

Taking foot control to the next level

In response to requests from a number of surgeons, Advanced Medical Optics (AMO) is now making available a new optional version of the Sovereign Phaco System footpedal. This version of the footpedal can provide tactile feedback to make it clear when you're transitioning between foot positions 1, 2 and 3. It also provides additional programmable switches that allow you to turn continuous irrigation on and off without sacrificing control of reflux or multiple modulation phaco (MMP).

	AMO's new, optional footpedal for the Sovereign Phaco System is designed to give the surgeon more tactile feedback and control during surgery.

Tactile feedback. The new footpedal's tactile feedback can be turned on or off, and can be set to provide any of three different levels of feedback. (The higher setting works well if you wear shoes during surgery; lower settings are sufficient if you operate without shoes.) You can choose to have the feedback activate only when pressing down, or when moving the pedal in either direction.

Extra programmable switches. Two programmable ribbon switches have been added on top of the side switches. Like the other switches on the footpedal, they can be programmed to control MMP, reflux, MMP up, MMP down, or continuous irrigation. (If you choose to use a ribbon switch, deflecting the side switch will activate only the ribbon switch.) Attributes relating to all side switches are programmable for each mode: phaco, I/A, and vitrectomy.

Other new features include:

• The "bridge" style carrying handle that straddles the footpedal is removable to allow more freedom of movement during use. (The base plate of the footpedal includes a cutout designed to be used as an alternate carrying handle.)
• The ridge or "lip" found at the bottom of the footplate in previous models has been removed. This gives surgeons who have longer feet more room to position their feet comfortably on the pedal.

Advantageous features of previous versions of the footpedal are still part of this upgraded model:

• The foot controller can be used in toe-activated or heel-activated mode.
• Degrees of travel are programmable.
• Increased linearity and uniform pressure reduce foot and leg fatigue.

To use the new computerized features in this model, your Sovereign system must be using the upgraded WhiteStar software, version 5.0. (This is part of AMO's new technology that makes it possible to perform bimanual "cold phaco" surgery through very tiny incisions.) With this software installed, the Sovereign system automatically detects the new footpedal as soon as it's turned on.

More advances to come

In the near future, AMO also plans to introduce a new phaco handpiece for use in bimanual/sleeveless "cold phaco" surgery. Further details were unavailable at press time.

For more information about the new Sovereign Phaco System footpedal, contact AMO at (800) 366-6554 or www.Amo-inc.com.