OASC | SURGERY

Advanced Phaco Systems

Developments such as high-tech fluidics improve outcomes and safety for microincision cataract surgery.

By Erin Murphy, Contributing Editor

Advances in cataract surgery over the past decade have been dramatic, from instruments to surgical techniques to IOLs. Still, neither industry nor surgeons are resting on their laurels. Incisions are getting smaller and smaller, and there are more advanced IOL options than ever before. Phaco machines not only facilitate these changes with smaller incisions, but also raise the bar for safety and efficiency.

Surgeons looking to upgrade their machines can expect phaco tips for predictable microincisions, new handset features and a range of advances in the area of fluidics. In particular, if you’re interested in elliptical phacoemulsification or in gaining greater pressure control throughout surgery, you might look into trying some newer phaco machines. Colleagues who are using these systems praise their ease of use and, most importantly, their low rates of complication.

Centurion Vision System

“Cataract surgery is changing and will continue to change,” says James A. Davison, MD, FACS, of Wolfe Eye Clinic in Marshalltown, Iowa. “IOLs will be getting less bulky, which will enable us to use smaller incisions, and we’ll get to use smaller phaco tips as well. Those smaller incisions and microscopic surgeries will result in better, safer, more reliable recoveries and new machines will allow us to accomplish this.”

Dr. Davison with Centurion and VERION displays.
PHOTO COURTESY OF JAMES A. DAVISION, MD, FACS

Dr. Davison uses the Centurion Vision System (Alcon), a recent successor to Alcon’s Infiniti system. “It enables us to do an excellent job with the routine cases that make up 80% of our work, while also doing a faster, better, safer job on the 20% that are the tough cases,” he explains. “Many of those tough cases are hard cataracts, so having a machine that’s really good for hard cataracts is a great thing. The Centurion does a better job on hard cataracts than the Infiniti did. The Centurion’s Intrepid Balanced Tip provides a uniquely efficient tip motion. Because of that, movement at the shaft is relatively reduced by about 50%, so the chance for thermal effect at the incision is consequently reduced as well.”

The fluidics capabilities of the Centurion give Dr. Davison less concern about complications, such as intraoperative floppy iris syndrome (IFIS). “The Centurion also offers excellent fluidics controls, so I can operate on small pupils or patients on tamsulosin hydrochloride (Flomax, Boehringer Ingelheim Pharmaceuticals) without worry,” he says. “I can treat these more like routine cases. Turbulence is reduced and pupils don’t come down.”

Dr. Davison likes many features of his system, but he emphasizes that the advancement of microincision surgery alone makes it an excellent choice. “The system has a cordless foot switch that everybody in the room loves because it means fewer cords and less clutter. Two computer-controlled plates squeeze the BSS bag gently to provide a constant IOP rather than relying on gravity and a hanging bottle. And the vitrector cuts at an unheard-of 4,000 cuts per minute, a speed that’s used all the time for vitrectomy,” he says. “The system helps us now and prepares us for the future. We always have to be optimistic and think long term — if something is faster, better and safer, it’s worth the investment over time. I think this system will get us through the next 10 years very nicely.”

WHITESTAR Signature System

“Fluidics have become more and more important in cataract surgery for both efficiency and safety. With patients presenting for refractive cataract surgery earlier and with the advent of the femtosecond laser, we’re dealing with softer cataracts than before. With many of these cases requiring less phaco power, the fluidics become the critical component, and one of the most advantageous features of the WhiteStar Signature System are the advanced fluidics,” says Tal Raviv, MD, FACS. Dr. Raviv practices at New York Laser Eye in New York City and is an assistant professor of Ophthalmology at the New York Eye and Ear Infirmary.

Dr. Raviv says that the two pumps in the WHITESTAR Signature System give him exceptional control. “The system has the ability to sequentially use true peristaltic and true Venturi pumps for different steps in the same procedure,” he explains. “The design allows us to utilize the holding power of the peristaltic pump during lens disassembly. After we’ve broken up the cataract by cracking or chopping, we switch over to venturi fluidics to draw the pieces safely to the phaco tip. With Venturi, there’s no need for the phaco tip to travel to the periphery. We remove the pieces easily and quickly, without full occlusion, while saving fluid in the eye and causing less damage.”

The phaco tip’s elliptical movement makes surgery safer as well. “The WHITESTAR Signature System uses proprietary elliptical phacoemulsification technology. The longitudinal and lateral energies blend into a smooth elliptical movement,” he says. “There’s less repulsion at the tip, so we can use lower fluidic parameters. This allows for safer, more effective lens emulsification and requires fewer lower settings overall. For example, when I’m down to the last quadrant, my Venturi vacuum is set no higher than 100 mm Hg, rather than the high vacuum levels of 500 mm Hg that other systems may use. I remove the last quadrant safely, with fewer risks and complications.”

Dr. Raviv anticipates continued updates to the WHITESTAR Signature System. “Traditionally, phaco systems have been updated with major machine cycles, but there are also more common software upgrades every couple of years to enhance various features. New phaco tips are continually introduced for smaller incisions and new tools to assist with femtosecond laser cataract surgery are in the works,” he says. “We have the best of both worlds now — low-energy, safe fluidic systems for the softer, younger lenses of refractive cataract surgery, as well as the ability to safely treat dense cataracts with the Ellips FX technology. The femtosecond laser can be helpful in both scenarios.”

With the WHITESTAR Signature System, Dr. Raviv’s Venturi vacuum is set no higher than 100 mm Hg when he is down to his last quadrant.
PHOTO COURTESY OF TEL RAVIV, MD, FACS

Stellaris Vision Enhancement System

Louis D. “Skip” Nichamin, MD, is medical director of the Laurel Eye Clinic in Brookville, Pa. He uses the Bausch + Lomb Stellaris Vision Enhancement System and was involved in the system’s inception and design.

“I think the Stellaris represents the best technology, picking up where its predecessor, the Millennium, left off,” he says. “I want the safest, most effective phaco technology in my hands, and I think the Stellaris achieves that by giving surgeons the best fluidics.”

Dr. Nichamin’s high praise for the Stellaris’ fluidics stems from its vacuum-based technology. “It’s the new generation of very efficient, high-performance vacuum-based pump technology. The Stellaris has forced infusion pressure, rather than a gravity-based hanging bag, which gives me very precise pressure control. I couldn’t imagine using anything else today,” he says.

According to Dr. Nichamin, fluidic control translates to better safety and fewer complications. “Consistent, controllable fluidics limit the chances of the most common complications, such as rupture of the posterior capsule,” he explains. “The system’s refined fluidic control and management on both the infusion and the aspiration sides — combined with the 1.8 mm microincisions that the system facilitates — leads to improved safety and stability in the eyes.”

With greater control over intraocular milieu, Dr. Nichamin says he’s able to handle complex cases more easily, including intraoperative floppy iris and small or large pupils. “Pump systems perform extremely well for those of us who often deal with complex cases,” he says. “A unique feature of the Stellaris is that if there’s a complication such as a damaged posterior capsule and vitreous loss, the vacuum-based system’s high cutting rate and smooth fluidics give us the ability to perform a very advanced and efficient vitrectomy — something one wouldn’t think of doing with a peristaltic pump.”

In addition to the clinical advantages Dr. Nichamin attributes to the Stellaris system, ease of use is another factor that makes it attractive. “Nothing is less efficient than a complication, so a good system is generally an efficient one,” he says. “But in day-to-day use, ease of use and efficiency become major criterion. The design team went to surgeons and staff to create a better approach to intraoperative efficiency and user friendliness. It’s mobile, with a very small footprint in the OR. It’s very logical and simple to use, and setup time is quick, which is very important in a high-volume setting like mine.”

Ocusystem ART Phacoemulsifier

“We’ve had Surgical Design phaco machines through three generations of the Ocusystem, starting 30 years ago when we opened the first freestanding ophthalmic ASC in Michigan,” says E. Mike Raphtis, MD, Medical Director of Balian Eye Center in Rochester, Mich., and Clinical Associate Professor at Ferris State University in Big Rapids. “We love performing microincision phaco surgery with the Ocusystem because the procedure results in excellent outcomes and minimizes infection and other complications. Safety is so important to us. We’ve had only six unplanned vitrectomies in the past 12 years, and our endophthalmitis rate is less than 1 in 3,000 cases.”

John V. Balian, MD, founder of the Balian Eye Center, chose the Ocusystem for practical, economic reasons, and those reasons remain valid today. “Originally, we chose the system to save costs with reusable tubing,” Dr. Raphtis says. “We still love that cost-saving measure, but we’ve also found that the systems have been excellent workhorses for cataract surgery. They do an outstanding job while being very low maintenance. That means the Ocusystem is still very economical for us, while providing the level of performance we want in the OR.”

Surgical Design has a long history of innovation, its leaders having designed the first patented phacoemulsification machine. Dr. Raphtis is excited about the new Ocusystem handpiece currently in development. “We’ll be able to perform phaco followed by irrigation, and aspiration with a single handpiece instead of switching instruments. The bilumen handpiece has a phaco needle for cataract extraction and an adjoining tube for infusion. After phaco, the handpiece function will instantly switch to irrigation and aspiration in this new design,” he explains. “Eliminating that extra step in surgery saves time. It’s one of those revolutionary ideas you can’t believe hasn’t been thought of until now.”

Several Systems, One Consensus

“Phaco is a competitive environment, and there’s an unmitigated desire from both surgeons and industry to see better instruments with advanced software, needle design and fluidics,” says Dr. Nichamin.

His Stellaris system fills his needs, but surgeons have their choice of several systems. In comparing them, we get a complete picture of today’s cutting-edge cataract surgery.

Phaco tip design is enabling surgeons to give patients all the benefits of microincision surgery. Elliptical phacoemulsification permits them to use lower pressure, which is in turn supported by advances in fluidics. Fluidics based on pumps, rather than gravity, give physicians greater control for easier removal of both soft and hard cataracts. They experience complications, such as IFIS or rupture of the posterior capsule, less often. Even the surgeon’s own comfort and efficiency are enhanced by new pedal and handset designs.

Phaco systems are designed to let you perform the best cataract surgery today and prepare you for tomorrow.

Dr. Davison is prepared for the future. “We’re all using some generation of phaco technology,” he says. “but to be ready for better microincision surgery, we all need upgraded systems.” ■