spotlight on technology & technique
An Alternative to Ultrasound
The AquaLase modality of the Infiniti Vision System looks like a real contender for emulsifying cataracts.
By Christopher Kent, Senior Associate Editor

Progress often involves fine-tuning existing technology. Occasionally, however, an entirely new way to solve a problem appears. If the new approach is effective and offers advantages over the previous technology, there's a good chance it will eventually take its place next to -- or even surpass -- the older alternative.

Alcon's Infiniti Vision System for cataract removal offers both kinds of advances. It lets you choose from three different technologies for cataract removal. Two are enhanced versions of ultrasound phacoemulsification (one of which combines ultrasound and oscillation using the NeoSoniX handpiece). The third option is AquaLase, a unique system that breaks up cataracts using pulses of warmed fluid (BSS).

The AquaLase system is still new, but a number of surgeons have now used it enough to have a good sense of what it can do -- and how it compares with standard ultrasound phaco. Here, we've invited some of these doctors to share what they've learned.

The AquaLase handpiece (above) uses pulses of fluid to break up a cataract. (Below: Alcon's Infiniti Vision System.)

Making the Switch

Rolondo Toyos, M.D., is in private practice in Memphis and Jackson, Tenn.; he's performed more than 500 cases using AquaLase. "The thing that always frustrated me about ultrasound," he says, "is that you sometimes have what appears to be a perfect case; then the patient comes back with corneal edema.

"Using AquaLase, corneas come out clearer and there's not as much structural damage. Now, when doctors refer patients to me, the one comment I hear most often is, 'That eye looks so quiet, so clear.'

"We're doing a study using specular microscopy to measure endothelial cell counts before and after surgery using AquaLase. So far, the endothelial cell counts are showing that corneas are minimally affected by the surgery."

Robert J. Cionni, M.D., who practices at the Cincinnati Eye Institute in Ohio, currently uses AquaLase in about one third of his cataract cases. "I only use it on softer nuclei -- grade 2+ or less," he explains. "It works very well. It feels very safe. You're working with a soft polymer rounded tip instead of a sharp metal tip, and you're not putting high frequency sound waves into the eye. The eyes postoperatively look just phenomenal."

Dr. Toyos also appreciates the AquaLase tool's soft polymer tip. "We have video of high vacuum in the eye where the bag goes into the tip of the AquaLase port, and it doesn't rupture," he says. "I even use AquaLase to clean the lens capsule. I don't have clinical data, but I believe that 'pressure washing' the posterior capsule decreases the amount of posterior capsular opacification."

Robert P. Lehmann, M.D., clinical associate professor of ophthalmology at Baylor College of Medicine in Houston, Texas, says he loves the AquaLase technology; he prefers to use it in at least a third of his cases. "I find the corneas are crystal clear the day after surgery," he says. "Granted, most of us see clear corneas after using ultrasound, but I think I can see a difference, although I can't back that up with endothelial cell data at this point."

The Issue of Technique

While most surgeons still don't feel comfortable using AquaLase on dense cataracts, Dr. Toyos says he now uses AquaLase exclusively on all of his cases. "I did have to develop a technique for removing the densest cataracts," he says, "but using ultrasound for this requires special techniques, too.

"I get calls from surgeons who've tried AquaLase, saying it didn't work very well. That's because they're using their standard phaco technique. Unlike ultrasound, AquaLase breaks up the nucleus by striking it repeatedly with pulses, like a boxer throwing punches. Because fluid is non-compressible, a hard nucleus will tend to move away from you. I put my second instrument behind the nuclear fragment to prevent this -- something I would never do when using ultrasound."

Developing a new technique takes time, he notes, and surgery may go more slowly during the learning curve. "When I first started, AquaLase cases took longer than my ultrasound cases. Today, my AquaLase cases go just as fast. I simply had to learn to use it."

Dr. Lehmann agrees. "The more I use it, the more skilled I become at removing denser nuclei. Today I wouldn't use it to remove a grade 4 nucleus, but I find it much easier to manage grade 3 nuclei now than I did only 6 months ago. It gets better as you work with it."

A Marketing Advantage?

Like any new technology, AquaLase has the potential to be used as a marketing tool. Of the three surgeons we spoke to, only Dr. Toyos has tried this so far -- with some success. "Patients have a hard time understanding how ultrasound works, but they find "water-based" technology appealing. In fact, doing all my cataract surgery with AquaLase has become a big advantage. We've advertised it a little bit; I've gone on local TV and we did a write-up in the local papers."

Dr. Lehmann says his practice doesn't currently use AquaLase as a marketing tool. "But there's something about new technology," he notes. "Patients talk. They know it's new and produces great results. They're excited."

Like Dr. Lehmann, Dr. Cionni hasn't used AquaLase as a marketing tool so far, but believes the news is spreading by word of mouth. "We'll definitely start advertising when we tie the AquaLase modality to clear lens exchange," he says. "Those patients usually have soft cataracts, and being able to advertise safer lens removal than phaco should provide a real marketing advantage."

Outlook: Excellent

Dr. Toyos' faith in the AquaLase system is clear. "When I first began using AquaLase, I expected to use the ultrasound capability of the Infiniti System as well. But after I tried ultrasound again, I decided I wasn't going back."

Dr. Cionni notes that it's going to be hard to outdo phaco. "But AquaLase is at least as good as phaco," he says, "and it's safer. Also, AquaLase is in its infancy compared to phaco and Alcon is constantly improving its capabilities. If we can obtain at least the same quality of results as phaco and do it more safely, we've got a winner."

To find out more about the Infiniti System or AquaLase, call (800) 862-5266 or contact your Alcon representative.

Drs. Lehmann and Cionni are consultants for Alcon.