Emerging phacoemulsification technologies continue to decrease the size of our cataract incisions
Over the past decades, the technique of cataract surgery has changed tremendously. From extracapsular scleral tunnels to clear corneal incisions, patients have benefited from the improved rapid physical and visual rehabilitation. While phacoemulsification via clear corneal incisions has become the preferred technique of cataract surgeons, improvements are constantly being developed. Currently, advances in phacoemulsification are taking the form of smaller incisions. Benefits of smaller incisions include less induction of astigmatism, less egress of fluid, increased wound stability and a likely decreased risk of endophthalmitis. While microincisonal phacoemulsification has been accessible in other countries, only recently has it become widely available in the US via two systems: The Bausch and Lomb Stellaris and Alcon Infiniti Intrepid systems.
The Stellaris Vision Enhancement system is available with flow based or vacuum based modules. With this system phacoemulsification can be performed through a 2.0 mm incision. A straight tip six crystal handpiece is utilized which produces a resonant frequency at 28.5 kHz. An increased stroke length allows more efficient energy transfer compared to their earlier Millenium model. While no intraocular lens is currently available for this small an incision in the US, B&L plans to launch their small incision ready Akreos lens soon.
The Alcon Intrepid microcoaxial system is based on the Infiniti system and allows phacoemulsification on a Kelman tip handpiece through a 2.2 mm incision. The unit incorporates Ozil torsional technology to improve cutting efficiency. Currently Alcon has available a new Monarch III D cartridge that is 33% smaller in nozzle tip compared to the C cartridge. This allows their entire line of Acrysof Aspheric IOLs (including RESTOR) to be implanted without enlarging the wound size.
I had the good fortune to be able to sample both of these products and I was very impressed with both machines. Capsulorhexis required a very slight change in the way I hold my Utrada forceps however it was still easy to perform through a smaller incision. Anterior chamber stability was maintained throughout all cases and there were no moments of surge whatsoever. Intraocular lens implantation of the Acrysof lens was very easy to perform with the D cartridge through a 2.2 mm incision. At the conclusion of the cases the incisions were water tight without need for stromal hydration. On post-operative day 1 all patients had clear corneas with sealed incisions.
Overall, the new technology took only a few cases with very slight modifications in my technique to adapt and feel comfortable with. At this point I anticipate performing 100% of my cases via microcoaxial phacoemulsification and encourage those surgeons not familiar with these systems to evaluate them. The benefits are well worth the small learning curve.
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