Extended posterior offset sets the Tango Reflex Neo YAG/SLT laser apart.

With up to 40% of cataract patients expected to develop a posterior capsular opacification (PCO),¹ surgeons need to ensure optimal PCO care. The Tango Reflex Neo YAG/SLT laser by Ellex from Lumibird Medical can help physicians provide that care (Figure 1).

With this new generation of the company’s Tango Reflex laser, surgeons can perform capsulotomies with an extended posterior offset, precise incisions and improved accuracy in targeting — a combination that Lumibird refers to as Premium Refractive Outcome Capsulotomy, or PROcap. PROcap represents “the key difference that we bring to market with this laser,” says Matthew Metcalfe, anterior segment laser product manager at Lumibird.

EXTENDED OFFSET

As opposed to an industry maximum of 500-mm offset, according to Mr. Metcalfe, the Tango Reflex Neo laser offers settings at 1,000 and 2,000 mm. These offsets, he says, position the treatment beam much deeper in the vitreous.

“You shoot at the capsule, but the focus of the laser is automatically placed more posterior to the IOL,” says Karl Brasse, MD, MRCOphth, medical director, Oogcentrum Eibergen, Netherlands (Figure 2). “That is the key: Displace the focus up to 2 mm behind the IOL.”

That ability to go deeper into vitreous harnesses the properties of cavitation. “Plasma from the YAG laser creates cavitation, and by using the power of the cavitation bubble implosion, the procedure becomes more efficient. We’re able to create a larger area of disruption of the capsule with each shot compared to using the plasma energy close to the lens,” says Inder Paul Singh, MD, president and head of the glaucoma division of the Eye Centers of Racine and Kenosha, Wis.

With conventional YAG offsets, according to Lumibird, the cavitation bubble generated by the laser collapses and the laser’s mechanical wave disrupts the posterior capsule. By comparison, with the up to 2,000-mm offset of the Tango Reflex Neo, the cavitation bubble collapses and propels a high-speed liquid jet towards the IOL, efficiently cutting the posterior capsule membrane.

Besides efficiency, this offset greatly reduces the chance of damaging the IOL. “It does help to prevent pitting of the lens,” says Dr. Singh. “We’re utilizing the properties of cavitation to disrupt the capsule without disrupting the IOL itself. Unlike manually guessing our position, by using the 2,000-mm offset, we can be confident that we are consistently far enough away from the posterior capsule to prevent pitting.”

STARTING AT THE CENTER

What’s more, with the posterior offset in the Tango Reflex Neo laser, a surgeon can perform PCO starting in the center of the capsule instead of using a more traditional circular pattern. The laser allows the surgeon to create a symmetrical, well-crafted capsulotomy without producing floaters, Mr. Metcalfe notes.

“You can efficiently create a nice 5-mm opening, close to the edge of the optic, very efficiently even if you start in the middle,” Dr. Singh says. The laser “gives you the flexibility of starting in the middle, performing a circular pattern while feeling confident knowing you are far enough away from the lens to prevent inadvertent pitting of the lens because of that 2-mm offset. Due to the efficiency and control of the energy, you can really create an ideal size and shape of these capsulotomies.”

INCISION PRECISION

The Tango Reflex Neo offers a sharp rise and fall of the waveform that results in more directed and less wasted energy, according to Dr. Singh. Lumibird says it delivers a 4-second Ultra-Gaussian pulse at high peak power, typically achieving the industry’s lowest optical breakdown of 1.4 mJ in air. “It’s very precise, and you can go to higher levels of energy in the YAG laser and not have a larger disruption in terms of collateral damage,” says Dr. Singh.

ILLUMINATION OPTICS

With “True Coaxial Illumination” (also available in the previous-generation Tango Reflex laser), a surgeon can better visualize the capsule and other structures. The titratable illumination can run from full to partial or no red reflex, providing spatial integrity and excellent contrast of ocular tissue, says Lumibird. The laser also offers a green aiming beam to provide a high degree of visual contrast.

In 2017, Dr. Singh presented a paper at ASCRS demonstrating fewer complaints of floaters post-YAG capsulotomy when using this coaxial illumination technology.²

“With this coaxial illumination system, you’re able to see fragments of the capsule created by the laser that you sometimes can’t see when you’re using a standard noncoaxial YAG laser,” says Dr. Singh. “Sometimes those pieces hide and can lead to patient complaints of floaters postoperatively. Better visualization of the capsule and behind the capsule allows you to not only see the capsule better, but also to actually see those small remnants and treat them accordingly.”

ADDITIONAL IMPROVEMENTS

The Tango Reflex Neo also offers a heads-up display with a dual-function joystick that allows the surgeon to adjust the energy and fire the laser.

In addition, for SLT, in a previous generation of this laser, the surgeon needed to be off axis with the illumination tower, which can be somewhat difficult for surgeons who are not accustomed to using a gonioscopic contact lens on the eye, notes Mr. Metcalfe. The Tango Reflex Neo, however, offers the ability to move the mirror vertically. “We’ve simplified the SLT approach,” he says.

A fan integrated into the laser’s slit lamp enables the laser to maintain a constant temperature, allowing the device to fire up to four times per second.

PREDICTABILITY & PRECISION

With the Tango Reflex Neo, both providers and patients can have higher expectations for cataract surgery than ever before. “Now that we have more predictability and more precision with our technologies preoperatively and intraoperatively, we’re able to achieve remarkable outcomes,” says Dr. Singh. OM

Dr. Brasse reported no relevant disclosures. Dr. Singh is a speaker and consultant for Lumibird.

REFERENCES

1. Krajcová P, Chynoranský M, Strmen P. Opacifikácia zadného puzdra sosovky po implantácii rôznych typov umelých vnútroocných sosoviek-- II. cast: rôzne peroperacné nálezy [Posterior capsule opacification following the implantation of various types of IOLs--part II. Different intraoperative findings]. Cesk Slov Oftalmol. 2008 Jan;64:13-5. Slovak. PMID: 18225493.
2. Singh IP. Floater Incidence After Capsulotomy with a multi-modality Nd:YAG laser. ASCRS Annual Meeting. May 5-9, 2017. Los Angeles.