The Latest In Cataract and Refractive Surgery


Advances in phaco technology were the big hit at this year's ASCRS conference.

My hometown, San Diego, has a lot to offer. A world famous zoo, the Padres, fish tacos and, for a few days last spring, the 2007 gathering of the American Society of Cataract and Refractive Surgery. During what was essentially a stroll through my backyard, I cased the conference's exhibit hall for the latest in ophthalmic equipment and supplies. I discovered advances in phaco machines and surgical microscopes, an enhancement to a leading accommodative lens and fresh options in instrumentation. Here's a recap.

Fluidic finds
Advanced Medical Optics showcased its WhiteStar Signature Phacoemulsification System. WhiteStar technology is said to keep the lens and phaco tip in contact throughout the procedure, a development that increases cutting power, allows for better control and a more stable chamber, and lets the surgeon operate with more aggressive parameters. The company claims the Signature system, which costs between $70,000 and $75,000, combines the performance of venturi and peristaltic pumps to provide a more stable operative field.

With increased chamber stability through enhanced fluidics a surgeon can take advantage of quicker follow ability, better hold ability and more efficient cutting without sacrificing control. So emulsification is done faster with less fluid usage and with increased control and safety.

When choosing between venturi and peristaltic modes, most surgeons prefer what they trained on. It's like deciding between a Ferrari and a Cadillac. You can't go wrong with either and should base your decision on individual preference. However, each mode has its benefits and more sophisticated surgeons can take advantage of those benefits by having the capability to toggle between modes in a particular situation. That's a nice option.

On the perioperative front, scrub techs can load the system's cassette themselves. That's helpful. Having a single-person cassette-loading system increases efficiencies by letting the scrub tech set up the machine independently without having to wait for the circulator. The system's wireless foot pedal means one less cord to trip over, one less cord to clean and one less cord to manipulate each time you have to reposition the foot control.

Bausch & Lomb says its Stellaris Vision Enhancement System lets surgeons perform standard coaxial, sub-2mm micro incision coaxial and bimanual phacoemulsification surgery. The system is customizable for either vacuum (venturi) or flow-based (peristaltic) fluidics.

It's obvious that the Stellaris system was designed with a nod to the needs of the surgical team. The system boasts a compact design and 18-inch high-def monitor. It's also user-intuitive with animated "show-me" setup steps appearing on the screen. The system's cassette fits easily into the front of the unit and is an advanced system flow model that does not require nitrogen.

A smaller more compact unit is always an advantage. It's no secret that ORs tend to be loaded with equipment that can impede the ability of the staff to move efficiently. The "show-me" setup provides an on-the-spot in-service for staff who may end up working eye cases without recent experience in that specialty.

The system allows for better fluidics controls, meaning less BSS is used. Better fluidics implies better control of fluid going in and out of the eye. This means the eye chamber is more stable with less fluctuation in pressure, which is better for patient safety and for avoiding complications.

One additional feature: controls at the system's back regulate IV height, which the circulator can easily access without having to get in the way of the sterile team and field.

Instrumental upgrades
Oasis Medical introduced its Feather and Premier Edge safety scalpels. Both the Feather and Premier Edge blades offer facilities an opportunity to comply with OSHA regulations requiring the use of scalpels with a safety mechanism to guard against sharps injuries. Both of these ophthalmic scalpel styles will be available in a variety of blade configurations.

The Visitec disposable line from BD Medical includes Bonn forceps, Capsulorhexis forceps, Macpherson forceps, eye speculum, needle holder, Vannas scissors, Buratto's hook and straight micro-manipulator. These are nice tools and can reduce the potential for infection associated with reuse - a big concern given the unnerving re-occurrence of TASS outbreaks that continue to plague facilities without an apparent common cause.

Rhein Medical's Eco single-use instrumentation was on display. Rhein also showed lens loading forceps designed to protect the Visian ICL when loading the lens into the injection cartridge from the proximal end. The company's Brown Triple Post Speculum is said to improve access and visualization of the superior cornea by creating an oval separation of the lids and by preventing drape obstruction.

SharpGuard guarded knives are a new entry into the safety scalpel market. The line is offered in stab, slit and crescent configurations and labeled for single use. Each design boasts a textured sheath that is retracted during use and extended back over the blade before or after surgery. The manufacturer, Surgical Specialties, says the blades are not yet commercially available, but will hit the market soon.

With so much emphasis on case cost management, the cost of all these single-use instruments, as with any disposable item, has to be weighed and balanced against the impact on the procedure's overall supply costs and the potential for aiding in infection control efforts.

AISCO's Pre-op Toric Reference Marker lists for $497 and is suited for marking the eye before implanting the AcrySof Toric IOL. The neatest aspect of the instrument's design was the built-in level bubble that tells the surgeon when the marker is exactly horizontal. Its handle is removable, making it autoclavable without fear of damage. AISCO also displayed its Arnold Guarded Speculum. The company says the speculum's blades are designed to protect the operative field from touching a majority of the lid margin, thereby reducing the field's contact with a major source of bacteria.

Along those lines, Ocusoft was on hand to showcase its Lid Scrub Plus and Advanced Vision Research showed off its SterLid Eyelid Cleanser. Ocusoft says its Lid Scrub Plus combats moderate to severe eye conditions. In studies, the pre-op cleanser was shown to be effective in reducing S. epidermidis, a common cause of post-op endophthalmitis. It comes in pre-moistened pads or a foam pump dispenser; 7.25 fl. oz. lists for $13.95

Advanced Vision Research says its cleanser, when used by patients twice a day for 60-second intervals three days prior to surgery, can help reduce incidences of intraoperative infections. It is said to enhance the skin's natural defense against bacteria by maintaining oils that have antibacterial properties. This over-the-counter treatment option costs $18.99 and could be a nice adjunct to your infection control efforts.

Scoping your options
Prescott's Omni-Flex microscope runs about $29,000 and comes with a two-year parts-and-labor warranty. The new scope sits on an American-made stand and features German Haag/Streit optics, highlighted by apochromatic lenses and a red-reflex enhancement system - a hot topic in developing ophthalmic scopes. A Prescott's rep said the optics provide an optimal view of the posterior capsule with a red reflex enhancer. A strong red reflex helps to make structures in the eye more easily viewed and with greater detail because of the reflective light off the retina.

The company also displayed its Medicap USB200, a device designed to digitally capture video and still images for storage on your existing computer without the need of a full DVD recording system. For around $4,000, you'll get a plug-and-play box that is universally compatible with standard video connections. Once connected to your scope, the Medicap captures images with a quick push of a button or flick of the foot switch. Instead of burning images to a DVD, you can plug a flash drive into the system's USB port for later image downloading and viewing on your personal computer.

Endure Medical threw its Reflex Scope into the mix. The company says the scope allows for presets of surgeon name, illumination level, X/Y-focus-zoom-speeds, foot control configuration, bulb check and system diagnostics. A complete secondary illumination source combines with the programmable settings to create a one-touch button that readies the system before each case. The scope's foot pedal is waterproof and surgical assistants can control all motorized features of the scope if the foot pedal fails during a procedure.

The surgeon preference setting is a nice feature, particularly when you have staff in the OR who don't normally work with that surgeon. Having the microscope properly positioned and set is essential. If the staff is unfamiliar with the scope or the surgeon, it can take extra time - extra time that compromises efficiency.

One of the neatest devices, albeit perhaps most impractical for small surgery centers, was the TrueVision 3-D Imaging System by TrueVision Systems. Instead of peering through a surgical scope, surgeons don 3-D glasses (they look like sunglasses) to see the operative field displayed on a full color monitor. The system is said to improve surgeon comfort. That's true. But for the doc who is accustomed to doing 30 cataracts a day while looking through the eyepiece of his trusty scope, this technology would be a distraction. It is, however, ideal for teaching institutions and for training surgeons to better appreciate what they will view through the surgical microscope's eyepiece.

Best of the rest
Eyeonics presented the crystalens Five-O platform. This accommodating IOL lists for $895. The enhanced platform has a larger 5.0mm optic and is now available in an expanded range of 10 to 30 diopters - well beyond the range of current IOLs. It is also available in quarter-diopter steps to give surgeons more precise options. Eyeonics says the new platform is also available in a 12mm overall length (from 10 diopters to 16.75 diopters) to accommodate larger eyes.

The effective implantation of IOLs demands extreme precision, so the quarter diopter increments are a nice improvement. The expanded diopter range also makes this platform suitable for longer, more myopic eyes. One of the company's reps said the new lens is bulkier and therefore more stable and more predictable during implantation.

UFSK-OSYS showed off its surgiLine surgeon's stool. This battery-operated, rechargeable stool - the rep said the only one like it on the market - lists for $2,980 and features a central brake that works on all four wheels. The rep, who was more than happy to demonstrate, said the automated stool is height adjustable without electronic power cords or pumping action and houses the same battery used in the company's surgical tables. That battery, according to the company, can last two months between charges.

The stool also boasts an ergonomic seat and backrest designed to support surgeons' lower backs, enabling them to sit straight while operating. With an increasing emphasis on ergonomics and work related injuries, this seems like a nice option and I frequently get requests from surgeons for a more comfortable and ergonomic stool.

One device displayed by NeoMedix, the Trabectome, is not new but could play a more prominent role in ASC case mixes over the next couple of years. The Trabectome, designed for trabeculectomies, is a disposable handpiece that combines bipolar micro-electrocautery and aspiration for a quick, minimally invasive, open-angle treatment of glaucoma.

A NeoMedix rep said trabeculotomy's average reimbursement (procedure code 65850) is currently slanted in significant favor of the HOPD ($1,413) when compared to the ASC ($740). Payments to the ASC, however, are expected to rise in 2008 and beyond. NeoMedix says the Trabectome's current distribution is limited to hospital settings but that may soon change as long as ASC payments improve and the Trabectome continues to show positive results. This device isn't a viable purchasing option right now, but might be worth keeping on your radar over the next few years.

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