Ophthalmologists aren't the only ones who've benefited from recent advances in phaco machines. While surgeons now enjoy an even wider margin of safety with more precise controls and a greater diversity of instrumentation, more manufacturers are focusing on ways to help nurses and techs with user-friendly features. Here's what you should consider to get the easy-to-use phaco machine that will provide you with the power you want and the accuracy you need in the precise world of cataract surgery.

• Set-up and tear down. Setting up the phaco machine can create problems if there's confusion about how to hook up the tubing. Make sure that the software that comes with the machine tells you how to hook up the tubing, and that this requires minimal effort for the staff and few complications to slow them. You need to consider how long it will take to clean the machine and get it ready for the next procedure. For example, because spilled balanced salt solution can be very corrosive, it's important that the foot pedal be self-contained and waterproof, which can allow for faster breakdown and turnover.
• Display screen. You want your machine's display screen to be easily readable for everyone in the OR. Recently, in response to many surgeons' requests, some companies have connected the microscope to the control screen as an additional monitor in the OR. This lets the scrub nurse see the procedure on the screen as it's happening so she can better support the surgeon. Speaking of the display screen, you'll want a machine with intuitive interfaces and robust help screens that are easily accessed on the display to help your staff move efficiently through the procedure.
• Foot pedals and handpieces. Flexibility is the key when choosing foot pedals or controls for the phaco machine. Because surgeons will be controlling the pedals, be sure to get their opinion on various foot pedals before buying. You want to find a machine with a foot pedal that lets the surgeon change modes by simply moving his foot. Wireless foot pedals and controls can also increase intraoperative flexibility in that you don't have to worry about bulky cords or maneuvering in tight spaces. The ergonomics and weight of the handpiece are critical, as this is where the surgeon has to have the most precision and control.
• Presets. Most machines let you program settings in advance so that each surgeon can control the fluidics and followability of the machine. This can decrease case time because the surgeon can just pop in his settings and get to work rather than having to constantly adapt and adjust to the machine. Some machines even let surgeons download their phaco parameters onto a laptop that they can then upload onto the same machine in a different room or center.
• Fluidics. Fluidics, a term that refers to the inflow (irrigation) and outflow (vacuum) of BSS to and from the eye, is incredibly important in maintaining the pressure in the eye and removing particles from it. Most phaco systems use peristaltic pumps, which stop and start according to the surgeon's touch of a foot pedal. Newer advances give surgeons the option to choose a peristaltic pump or a venturi pump, which allow for more constant flow. The ability for the peristaltic pump to emulate a venturi system gives the surgeon the flexibility to increase and decrease flow at different times throughout the surgery. Some machines can measure both flow rate and vacuum levels, which are then sent back to the computer to control the peristaltic pump's ability to generate flow or vacuum response.
• Tip factors. Obviously, the operation of the machine itself during the surgery is important to both surgeons and patients. The goal with cataract surgery today is to minimize the amount of time spent in the eye and to decrease the amount of energy that goes into the eye. One way of creating a safer surgery for patients is by using a handpiece whose phaco tip swings side-to-side at a lower frequency than the typical back-and-forth movement of traditional phaco tips. There is less heat from the ultrasound in the eye and less chance of the tip repelling nuclear material. Different tip sizes and angles can also be valuable in accommodating surgeons and case variety.
• Size. With newer technology comes smaller, more manageable machines. If you're not constantly moving your machine from OR to OR, then a larger machine might work for your facility. However, if you're storing the machine in a separate space or moving it often, you might want to look at the smaller machines that are available.
• Support. As with any piece of capital equipment, you want to make sure the company you choose to go with has a strong tech support system. Many newer machines employ an Ethernet port or some kind of connectivity to link the machine to service technicians via the Internet. This way, technicians can run diagnostic analyses to assess problems and quickly initiate corrective actions, meaning you'll spend less time on the phone waiting to talk to someone or waiting around for a part.
• Cost. No doubt a phaco machine represents a major capital investment. But you must also think about the cost of the tubing, phaco tips and sleeves, and whether they're reusable or disposable. Reusable tubing and phaco tips are FDA-approved for up to 20 uses, which can save your center money in the long run over more expensive disposable sets. However, with reusable tubing you must make sure to track it or manually estimate the use so you know when you need to get another set.

How long will the handpiece last before you need to replace it? You can estimate this by checking with the manufacturer. Can you substitute standard accessories for specifics? In addition, find out how many bottles of BSS the machine uses to determine the money you'll likely spend on this necessity. If you can figure out the cost-per-case at your facility, you'll be more likely to have an easier time budgeting for this expense.

The best thing you can do to help out your facility in terms of cost is to negotiate a good warranty and service contract and to thoroughly understand the terms of each. Be sure to ask what is covered in the warranty and what is not, and don't settle on a machine if it doesn't meet your standards.

• New technology. The first thing you need to ask yourself regarding new technology: Is the machine upgradeable? Can the machine support future software and features, such as retina? If not, then you need to consider whether you want to invest in something that may be technologically outmoded in five to ten years. Currently, companies are implementing many new features to increase usability, such as the ability to download a digital video of the surgeon's cases onto a laptop and Bluetooth dual-linear foot pedals. There continue to be advances in fluidics and energy use, and you want whatever machine you choose to be able to be a part of these advances.

What can you do?
The biggest issue that you'll face may not be the machine itself, but the surgeons who'll be using the machine. You need to consider what your surgeons want, but remember that if you have multiple surgeons in your facility, it might not be easy to find a machine that they all like. You'll need to find a machine that they're all comfortable with and you'll have to convince a few that the machine will work for them.

You should always get a trial in from every company for as long as possible; even if you're not sure one should be in the running, get a trial - you'll never know what a machine can do for you or your facility unless you try it.

In addition to your own trials, get the name of a colleague at another facility who's using the machine now and call the techs to get a real understanding of how well the machine works, its ease of use and other factors related to the performance of the machine. Never let a company sell you a machine with stipulations attached, such as package deals or bundling. You may find that if you choose a package deal you might have to go through many companies to get your IOLs, viscoelastic or other supplies, which might create more of a hassle for you and your facility than if you had the freedom to choose.

Alcon Laboratories
Infiniti Vision System with the OZil Torsional Handpiece
(800) TO-ALCON
www.infinitivision.com
Price: $99,800
FYI: Alcon's Infiniti Vision System offers the patented OZil Torsional Handpiece that delivers side-to-side oscillating ultrasonic movement to efficiently remove all lens densities. Surgeons can also use the AquaLase Liquefaction Device on soft- to medium-density cataracts to safely wash away lenses while optimizing capsular safety. The Infiniti Vision System's micro-coaxial lens removal technologies combine to offer surgeons efficiency and chamber stability, says Alcon.

American Optisurgical
Horizon Phacoemulsification System
(800) 576-1266
www.optisurgical.com)
Price: $17,000
FYI: American Optisurgical's Horizon Phacoemulsification System provides complete anterior cataract surgery functions, including multi-modulation phacoemulsification, "micro phaco," irrigation/aspiration, anterior vitrectomy and bipolar coagulation. The system features a large LCD touch screen with user-friendly controls, up to six user programs, burst mode, reusable or disposable tubing, an easy-loading tubing cartridge and an ultralight, 40khz, all-titanium, four-crystal U/S handpiece, says the company.

Advanced Medical Optics
Whitestar Signature System with Fusion Fluidics
(800) 366-6554
www.amo-inc.com
Price: Not disclosed
FYI: AMO's Whitestar system provides the ultimate chamber stability and effectively reduces post-occlusion surge by a significant margin, says the company. The dual pump responsiveness has the performance of a venturi pump and the control of a peristaltic flow-based pump to provide a stable environment for the surgeon and patient, says the company. The user-friendly system includes a one-step, one-hand cassette, an intuitive touchscreen and an intelligent help feature.

Bausch & Lomb
Bausch & Lomb Millennium
(800) 338-2020
www.bausch.com
Price: Not disclosed
FYI: Bausch and Lomb's Millennium system features programmable custom control software and Concentrix fluidics technology that allows an instant switch from vacuum to flow. The machine has a dual-linear foot pedal and a modular design that allows modules to be pulled out and easily replaced or installed, says the company.

Staar Surgical Company
Sonic Wave Phacoemulsification System
(626) 303-7902
www.staar.com
Price: $54,000 (complete system with touchscreen computer and cart)
FYI: Staar's Sonic Wave fragments lenses while operating in the sonic (40-500 Hz) frequency range, which uses up to 1,000 times less energy than standard ultrasound - effectively preventing corneal burns, says the company. The system offers excellent anterior chamber stability at all vacuum levels and uses auto-correlation that allows for customizable fluidics that can improve safety and speed.