It's quite simple, really. Surgeons want two things when it comes to cataract surgery: less energy and less time in the eye. You want faster turnover and a price you can live with. Your phacoemulsification machine can impact all these areas; even if the improvements you reap are incremental, every little bit counts in fast-paced cataract surgery.

We talked to the administrators at two high-volume ophthalmology centers that host many different physicians who use many different machines to find out what they and their surgeons need. Read on to learn about the latest upgrades to the phaco machines on the market, and how they can fit surgeons' needs.

Achieving less power
When you put less energy in the eye, you lessen the risk of damaging it. Unfortunately, ultrasound creates a lot of heat in the eye, creating the potential for a bad seal on the incision - which could lead to a post-op wound problem.

"Ultrasound is working," says Gina Stancel, HCRM, CST, COA, the surgical administrator for David C. Brown, MD, at the Eye Centers of Florida in Fort Myers, "but it isn't ideal."

To get around the drawbacks of ultrasound, some manufacturers are looking at ways to make ultrasound less potentially damaging. AMO's Sovereign Compact, for example, offers digitally modulated, so-called cold phaco - cold meaning that it "reduces heat, ultrasound energy and chatter," says Melissa Reece, RN, MSN, MBA, CNOR, the director of Cedar Laser and Surgery Center in Tacoma, Wash. This happens because, according to the company, the machine uses short microbursts of ultrasound energy.

Surgical Design's Ocusystem ART offers programmable energy bursts to achieve a similar effect.

And Bausch & Lomb has updated its Millennium with new Custom Control Software, which allows "a tremendous amount of programmability," says Uday Devgan, MD, FACS, an Assistant Clinical Professor at the Jules Stein Eye Institute at the UCLA School of Medicine, who participated in B&L's field observation study of the software. (He does not hold a financial interest in the equipment or software.) "In my average case, I do approximately 30 seconds of energy at 5 percent power. That's one second at 100 percent power, one second of absolute phaco energy," he says.

Some companies are moving away from ultrasound altogether. Laser and radiofrequency have, in the past decade or so, emerged and faded.

"We did laser here for a little while," says Ms. Stancel. "The laser was good, but it was a little difficult to prevent breaks in the laser tubing, and you couldn't resterilize it, which is expensive. It was also hard to figure out how to fit both the laser power and suction through the hole - we'd get a lot of clogged tubing."

Her facility also tried out radiofrequency phaco on pig's eyes. "The surgeons found it was hard to stabilize the chamber and get enough power," she says.

An alternative that looks as though it might last is Aqualase, an extra handpiece option on Alcon's latest machine, the Infinity. "It uses a fluid medium to emulsify the lens by more gently washing it away," says Ms. Reece.

Staar's Sonic Wave employs a proprietary sonic vibration fragmentation tool to use 200 times to 1000 times less energy than conventional ultrasound, says the company.

Faster in the eye and OR
"Speed and energy are sometimes a bit of a trade-off," says Ms. Stancel. "Keeping the eye open longer is obviously worse for the patient." It's also worse for your case volumes and, by extension, bottom line. Several phaco features contribute to speed:

• Programming. Being able to program settings in advance lets Dr. Devgan "put in my settings and crank out a case in five minutes flat - [the software] has decreased my total case time by about 10 percent." Most machines will provide you sufficient programmability; for example, American Optisurgical International's Sistem machine lets you set up to 12 user programs in advance.
• Intraoperative flexibility. "Surgeons like something that's flexible," says Ms. Stancel. She recommends looking for a machine with a foot pedal that lets a surgeon change modes by simply moving his foot. Some sort of alarm signal sounds to signal the change of modes, and there's no fussing with the machine itself.

A remote control is nice and lets the tech assist the surgeon quickly and easily. "But ours is bulky and wired to the machine," making it inconvenient, says Ms. Reece. A wireless remote is a better choice for helping to keep the intraoperative flow going.

• Set-up/tear-down. Look at machines with a practical eye - how long will it take to get the machine ready for a procedure, and how long will it take to clean up?

"I hear surgeons complain if it takes techs too long to set up the machine and test it," says Ms. Stancel. For example, having to change a cassette or open and thread a sterile set of tubing for every case "can be a pain for nurses and techs. Longer tubing takes longer to test, and that can hold things up, too."

Ms. Reece echoes these sentiments, and points to difficulty in cleanup as a factor that slows turnover. For example, the foot pedal on her facility's phaco machine is heavy, with many small channels and crevices; on high-volume days it is often splashed with BSS and accumulates lint from surgeons' socks. "It requires frequent cleaning, and I have to use cotton tip applicators and pieces of towels wetted with disinfectant and small enough to fit in the crevices," she says. "Cleaning the pedal is time-consuming; I would prefer an enclosed or encased pedal that we can easily wipe clean."

Cost factors
The phaco machine is your biggest one-time expense; but over the life of the machine, you'll probably spend more on BSS, tubing and phaco needles, so it's important to save if you can on these items. When you trial a machine, take note of how many bottles of BSS you need for a case. Ms. Reece's machine has a closed aspiration system - it minimizes air bubbles, improves aspiration and lets her use smaller phaco needles. However, it "primes with 60cc to 80cc of BSS per case," she says. "We have attempted to use less than one bottle per case but have been unsuccessful." Reusable tubing and phaco tips are also in demand. "A lot of the physician-owners wish they had more reusable options," says Ms. Stancel. "Thirty dollars or $35 or even $25 for tubing is a lot." Reusable tubing and phaco needles are FDA-approved for up to 20 uses, providing Ms. Reece with "significant cost savings over more expensive disposable sets." The downside, she says is that "tubing must be tracked or manually estimated and it is often discarded only when it malfunctions or appears worn." Another cost consideration: how long the phaco handpiece will last. Check with the manufacturer for their estimation; Ms. Reece's handpieces are recommended for 500 uses before replacement. "The company recommends budgeting for two new handpieces per year," she says, "but in our higher-volume center, digital handpieces have needed repair or calibration two or three times per year." Ms. Stancel recommends negotiating a good warranty and thoroughly knowing its terms.

Moving toward micro-incisions
Cataract surgery's trends are micro-incisions and bimanual technique, and equipment is beginning to reflect that. "For a while, all the research and development were being put into lenses and knives," says Ms. Stancel. "People are looking for a way to make smaller incisions and use less energy, so right now, it's back to phaco."