Do You Need A New Phaco Machine?

If your phacoemulsfication machines are more than three years old, it is definitely time to at least take one of the new machines for a test drive. No one relishes the idea of forking over big bucks for these instruments today, with cataract facility reimbursements on the decline. But most experts agree that features on the new machines make cataract removal significantly safer than ever before. Depending on surgical technique, the new machines may also make the procedure more efficient, saving OR time. Here's an update.

Why upgrade?
Many of today's machines incorporate features that make them significantly safer than the machines of old. "It's clear that the technology is better," says Larry Patterson, MD, an ophthalmologist and ASC owner in Crossville, Tenn. "There is no comparison," says Richard J. Mackool, MD, a New York ophthalmologist and ASC owner who has invented several phaco devices.

The biggest advances fall under the category of what phaco jockeys call "fluidics"-the manner in which the machine sucks material out as it pours new balanced salt solution in to replace it.

One fluidics advance is adjustability of the flow and vacuum. With most of the new machines, surgeons can choose low flow and low vacuum during the initial part of the procedure, when they are "sculpting" the soft portion of the lens but coming close to the iris and later the posterior lens capsule. With low vacuum, if the iris gets sucked in to the phaco needle, the surgeon has enough time to reverse course without damage. This is especially important if the surgeon uses the traditional "cracking" technique.

The new machines also allow surgeons to program them so that you can use really high vacuum when you've latched onto a piece of nucleus and want to apply phaco power. This feature is especially important if your surgeons use the newer "chopping" technique, because they often like to use high vacuum to hold the nucleus while chopping with the second instrument.

Once the nucleus is in pieces and the surgeon is ready to remove them, another new fluidics feature comes into play. During this phase, it can be helpful to use high vacuum, since you want the pieces of the lens to come to the mouth of the phaco needle. However, this can be dangerous with an older machine, because when a piece of lens material occludes the tip and vacuum builds and then breaks suddenly when the piece is sucked in, a large amount of fluid can be sucked in as well. Simple physics cause the anterior chamber to then collapse, bringing either the delicate corneal endothelium or the fragile posterior capsule dangerously close to the phaco tip. Endothelial compromise can lead to corneal transplant. Capsular rupture is a precursor to several sight-threatening complications, including CME and even endophthalmitis.

Many of the newer machines use multiple devices that help prevent this problem by keeping a good balance between the amount of fluid and material exiting the eye and the amount entering the eye. The methods vary from machine to machine; they include computer chips and software, rigid tubing, vented phaco needles and pressure transducers.

Besides fluidics, some of the newer machines also allow surgeons to titrate phaco power more. Old machines allowed only a linear application of power, but some of the new ones allow the surgeon to apply power in short bursts. This can be useful when performing delicate tasks. Choppers like it for impaling the nucleus, and crackers like it for removing the last quadrant of the lens.

The new phaco handpieces are also better. They get more power to the tip, which speeds emulsification and allows the surgeon to use less power in the eye. That should reduce wear and tear on the fragile corneal epithelium.

If your surgeons are especially adept, they may not need the above features to do phaco safely. But they may allow them to do phaco more aggressively, making it faster. Ft. Myers, Fla. surgeon David Brown is widely acknowledged to be the one of the fastest cataract surgeons in the world. Gina Stancel, his ASC manager, says upgrading to a machine with better fluidics allowed him to cut nearly a minute off of his surgery time.

How to Choose
If you have decided to consider upgrading your machine, there are several items to look into.

Since the most important consideration is surgical performance, investigate this first:

- View unedited video of the devices in use, advises Dr. Mackool. The vendor or a user may be able to supply one.
- Ask the vendors for referrals to local centers where the machines you are considering are in use. Go and watch the machine in action. Dr. Mackool says that this is particularly important when trying to evaluate fluidics, as it's very difficult to assess chamber stability via a two-dimensional view;
- Ask for a one or two-day demo of the machine. Try to schedule different kinds of cases, advises Ms. Stancel: "Normal cataract, a small pupil patient, a dense cataract patient, a pseudoexfoliation patient."

Allow as many of your surgeons as possible to use the machine. Most good surgeons can adapt to any of the new machines, our experts say. But if a significant number of your surgeons do not like the machine, you may need to rethink.

Bausch & Lomb's Millennium uses a new kind of pump that can mimic ventuir or peristaltic pumps.

Once you've assessed performance, consider cost per case. Dennis Shepard, MD, a Santa Maria, Calif. ophthalmologist and ASC owner, says this factor can be the difference "between being in the black or in the red." To understand why, do the math, advises Dr. Patterson. "If you do 1,000 cases a year and save $50 per case, that's $50,000 per year."

When determining cost per case, consider whether the phaco tips and tubing are disposable or reusable. If you are willing to use reusable tips and tubing, you can achieve significant savings. Joel Carlin, a certified ophthalmic technician with Southwestern Eye Center in Mesa, Ariz., says his center has reused tips hundreds of times. Dr. Patterson says he can autoclave the tubing on his machine up to 20 times before replacing it. Mr. Carlin says he uses disposable tubing, but only because his center has found an alternative source that provides it at $6 per case.

Many of our experts recommend insisting on learning the exact costs of all materials, even if you ultimately intend to sign a "package" deal where you buy your phaco machine over time by contracting to use the company's disposables and lenses.

Another consideration is priming. Units that use a venturi pump prime immediately with a minimum of balanced salt solution. Partially as a result, Ms. Stancel says Dr. Brown can get four to five cases out of one BSS bottle. Machines that use a peristaltic pump require more priming and more balanced salt solution-as much as 100 to 200 cc, says Ms. Stancel.

Ms. Stancel says it's easy to spend $200 per case if you are not watching costs. By being parsimonious, her center has reduced cost per case to less than $100, not including the cost of the intraocular lens.

If your center is busy or if you think it soon will be, you may also want to think about the ease and speed of turning over the machine. To assess this, Ms. Stancel recommends asking the rep to not participate in a case or two to allow the staff to change the machine over by itself.

Next, you may wish to consider reliability, service and warrantee.

To assess reliability, Dr. Mackool suggests good old fashioned networking. "Talk to people, log onto internet bulletin boards and evaluate complaints about machines, and call up your local hospitals."

Ideally, your supplier should have a field service person located near you. Ms. Stancel also has used her supplier's 24-hour service hotline, with good results. She also likes the modularity of her particular model, the Bausch & Lomb Surgical Millennium. "When something goes wrong, you can simply slide out the module and get a new one in 24 hours."

Obviously, it's to your advantage to obtain the longest warrantee you can, as phaco machines can and will break down.

Finally, consider your financing options.

Almost all companies offer financing. One way is via aforementioned contractual agreement to purchase the company's disposables and lenses. This can be advantageous if you do not wish to invest cash up front, says Dr. Shepard. It can also be very convenient for those opening a new center. Richard Lee, an ophthalmologist who just started a surgery center in Northern California, used this type of arrangement mostly because it was convenient. "We have one vendor for packs, lenses and sutures. They provide us with post-op bags, inserters, lens folders, viscoelastic, and free IOLs for patients in need."

If your principal concern is saving money, however, or if you want to have the flexibility to shop your supply contracts to different suppliers, don't do a "bundled" deal. "We buy our packs from one company and our implants from another and we got better deals individually than we were offered in packages," says Dr. Patterson. "Also, bundling really ties you down. What if someone comes out with a better implant and you are stuck with a contract to buy the old one?"

If you choose not to bundle, you can still typically obtain good financing from the supplier, says Dr. Shepard. He says deals are available for as long as 60 months, with low or even no interest.

Dr. Patterson suggests narrowing your choices to two suppliers, then inviting them to submit their best bid. Encourage creativity; the supplier may be very willing to throw in an extra handpiece or a three-month supply of tubing to get the deal, says Dr. Shepard. One last point: Instead of trading your old phaco machine in, consider donating it to a charitable ophthalmic organization like SEE International, says Dr. Shepard. You can write off the value of the machine, and help surgeons in developing countries give the gift of sight.