Cataract surgery may be the world's most successful and efficient outpatient surgery. The rate of serious complications is minuscule, and many surgeons can do the procedure in under 10 minutes. Yet the quest to produce technology that improves outcomes and shortens case times even more continues on, as you'll see in "The Latest in Cataract Extraction" on page 62.

Safe cataract surgery depends on keeping fluidic volume inside the anterior chamber — the tiny space where cataract surgery takes place — stable throughout the procedure. Phaco machines do this by infusing irrigating solution at the same time the surgeon is aspirating lens material. However, if fluid replacement lags behind aspiration too much, the chamber will collapse and the capsular bag will push forward.

"When you emulsify larger pieces of nucleus, it can obstruct the lumen," says Mitch Schultz, MD, a Pasadena, Calif., ophthalmologist.

When the probe suddenly sucks that nucleus in and occlusion breaks off, intraocular pressure can quickly drop and the posterior capsule can move forward. If the bag contacts the tip of the phaco probe as the surgeon is delivering ultrasound energy and aspirating, the capsule can rupture. Capsular rupture increases the risk for intraocular infection, swelling of the retinal tissue and retinal detachment.

• Stellaris Elite. Bausch & Lomb's new phaco platform works to precisely balance aspiration with infusion with something called adaptive fluidics. The technology continuously tracks vacuum flow rate second to second and then automatically adjusts infusion pressure. As with the Alcon Centurion, there is no longer a gravity system with a BSS bag on the pole. The Stellaris infuses fluid through a pump system.

According to proprietary B & L studies, the technology doesn't eliminate surges in pressure, but it works significantly better for this than any competing product. And watching the machine in action, it's easy to believe. After breaking up the lens, Dr. Schultz, who consults with B & L, says he can turn the vacuum all the way up to 600 mm Hg and simply hold the probe in the middle of the chamber. Fragments come to the tip with stunning speed. They occlude the tip and then break free, and the iris barely twitches.

"You can use high-vacuum settings from the start without worrying about damaging the posterior capsule," says Dr. Schultz.

He says he needs to use only about half as much phaco energy as he normally would. The system does cortical cleanup so well that Dr. Schultz has been able to switch from a bimanual two-incision technique to a coaxial one-incision technique. As with previous B & L phaco machines, the new unit doubles as a posterior segment machine (it emulsifies vitreous rather than using a guillotine). The Stellaris Elite is so easy that this reporter, who had never touched a phaco probe before, successfully removed a cataract and cortex from a porcine eye in a wet lab at the American Academy of Ophthalmology.

Easier subincisional cleanup

Once surgeons remove the crystalline lens, they have to remove the soft lenticular cortex. One challenge with that part of the process: how best to clear cortical material and viscoelastic that is directly under the incision? Here's a look at 2 devices aimed at easing subincisional cleanup.

• Intrepid Transformer. Alcon's I/A handpiece works with the Centurion phaco system, the market-leading platform that just turned 4. The Transformer quickly and easily converts from a coaxial I/A to a bimanual I/A. By twisting the back of the I/A handpiece, you can remove a separate polymer-tipped aspiration cannula. With the irrigation still in place, insert the aspiration cannula through the sideport incision. The device will fit through an incision as small as 1 mm. The aspiration cannula has an even wider aperture than the I/A tip, so it makes capsular cleanup and polishing much easier.
• Allegro SP I/A. The double-bend design of Microsurgical Technology's pre-assembled disposable silicone I/A system — resembling an eagle's beak — aims to let surgeons clean up under the incision without torquing the wound. You position the irrigation port very close to the aspiration to prevent the wound edges from blocking irrigation. No metal touches the capsule, only silicone, reducing the risk of capsular capture. You can also aspirate the IOL and dial it with this device, which is compatible with all phaco systems.

Can we eliminate phaco?

Phacoemulsification energy inside the eye can damage the delicate corneal endothelium. Too much damage rarely can result in a condition called bullous keratopathy, which requires corneal transplant. Two new no-phaco devices aim to change that.

miLoop. With Iantech's elegant miLoop, the surgeon makes an incision, and performs the capsulorhexis and hydrodissects as normal. But instead of inserting a phaco probe, he inserts the miLoop device tip inside the eye. A forward push of the slider atop the device deploys a tiny preformed nitinol filament loop. A slight twist of the device causes the loop to sweep under the anterior capsule, essentially lassoing the lens. Pulling back on the slider contracts the loop and bisects the lens. Dial the lens a few degrees and do it again.

Iantech points out 3 advantages with the miLoop:

• All the force moves centrally. There is zero stress on the fragile capsule or on the zonules that hold the capsule in place.
• It releases no phaco energy inside the eye, presumably helping to save corneal endothelial cells.
• It could be cheaper than phaco, especially in remote locations. The inventor, Sean Ianchulev, MD, MPH, is said to have originated the idea while slicing a slab of hard cheese with a wire cutter.

"It's great for rock-hard cataracts," reports Young Choi, MD, a Birmingham, Ala, ophthalmologist and a consultant to Iantech. "It uses no energy, no heat and therefore, less inflammation."

miLoop also loosens up the cortex, making cortical material easier to remove, and it reduces possible damage to the endothelium and zonules. Perhaps the best part, though, is that it could make modern cataract surgery more affordable and nix the need for phaco ultrasound in some cases.

CataPulse. CataPulse, a souped-up bimanual I/A system from Med-Logics, dissects and extracts the lens using high-frequency, pulsed vacuum technology. Instead of using ultrasound to make a sharp cannula vibrate, as with phaco, this system rapidly pulls lenticular material toward the tip and then releases it many times per second, emulsifying the lens by beating it against the tip. The makers say this eliminates phaco energy inside the eye. It also eliminates heat at the incision site. Without the need to cool the phaco tip, the irrigating fluids simply maintain the stability of the capsule as the cataract is vacuumed out. The downside is that the device doesn't emulsify as powerfully as phaco. It could take much longer to extract tougher, mature cataracts.OSM