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Update/Review New Phacoemulsification Technologies

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Update/Review New Phacoemulsification Technologies update/review New phacoemulsification technologies I. Howard Fine, MD, Mark Packer, MD, Richard S. Hoffman, MD To examine recent developments in the field of phacoemulsification, a literature review was conducted for each system described. The review included peer- reviewed articles, information from manufacturers, and meeting presentations by surgeons. Our personal experience with systems we have used forms the under- lying basis of our evaluation. Data for erbium:YAG laser phacoemulsification came from an interim summary of the U.S. Food and Drug Administration monitored study. Data for NeoSoniX came from a prospective evaluation of phacoemulsifica- tion in 25 eyes performed at the Oregon Eye Surgery Center. The development of new technology has allowed safer, more efficient phacoemulsification. Each sur- geon should evaluate new developments to achieve the greatest possible benefit for patients. J Cataract Refract Surg 2002; 28:1054–1060 © 2002 ASCRS and ESCRS ew technology brings challenges and opportuni- from the high-frequency ultrasonic waves generate even Nties to the anterior segment surgeon. The drive more heat. toward less traumatic surgery and more rapid visual re- Because of the liberation of heat, phacoemulsifica- habilitation after cataract surgery has spawned various tion needles have required an irrigation sleeve for cool- modalities for reducing incision size and decreasing en- ing. This irrigation sleeve carries heat away from the tip ergy use. and necessitates an incision larger than the tip alone Although ultrasonic phacoemulsification allows for would require. Nevertheless, standard ultrasonic phaco- relatively safe removal of cataractous lenses through as- emulsification with an irrigation sleeve has the potential tigmatically neutral small incisions, current technology for thermal injury to the cornea in case of diminished has drawbacks. In ultrasonic phacoemulsification, pi- flow. Flow and aspiration problems may be caused by ezoelectric crystals convert electrical energy into me- compression of the irrigation sleeve at the incision site, chanical energy, which emulsifies the lens material by tip kinking of the sleeve during manipulation of the hand- vibration. Ultrasonic tips create both heat and cavita- piece, tip clogging by nuclear or viscoelastic material, 1 tional energy. A conventional phaco tip moves at ultra- and inadequate flow rate or vacuum settings. Heating 2 sonic frequencies between 25 KHz and 62 KHz. The of the tip can create corneal incision burns. When in- amount of heat generated is directly proportional to the cision burns develop in clear corneal incisions, there may operating frequency. In addition, cavitational effects be a loss of self-sealability and corneal edema and severe induced astigmatism may result.1 Cavitational energy results from pressure waves Accepted for publication March 1, 2002. emanating from the tip in all directions. Although in- From Oregon Eye Surgery Center, Eugene, Oregon, USA. creased cavitational energy can allow for phacoemulsifi- None of the authors has a financial or proprietary interest in any material cation of dense nuclei, it can also damage the corneal or method mentioned. endothelium and produce irreversible corneal edema in Reprint requests to Mark Packer, MD, 1550 Oak Street, Suite 5, Eu- compromised corneas with preexisting endothelial dys- gene, Oregon 97401, USA. trophies. Reduction in average phaco power and effec- © 2002 ASCRS and ESCRS 0886-3350/02/$–see front matter Published by Elsevier Science Inc. PII S0886-3350(02)01399-8 UPDATE/REVIEW: NEW PHACOEMULSIFICATION TECHNOLOGIES tive phaco time has been correlated with improved tages over ultrasound as a modality for cataract extrac- patient outcomes after cataract surgery.3 Low-power tion have maintained interest in the laser. These phaco technology will have an important advantage in advantages include a relative reduction in the energy minimizing intraoperative damage to ocular structures requirement for cataract extraction and the absence of and maximizing the level and rapidity of the patient’s the potential for thermal injury to the cornea. However, visual rehabilitation. investigation has demonstrated that the efficacy of the The past decade has given rise to profound advances laser is limited to extraction of nuclear sclerosis of grades in phacoemulsification technique and technology. 0 to 3 and that phacoemulsification time with the laser, Techniques for cataract removal have moved from those although dependent on the surgeon’s level of experience, that use mainly ultrasound energy to emulsify nuclear tends to be longer than with ultrasound. material for aspiration to those that use greater levels of The Er:YAG laser produces a wavelength of vacuum and small quantities of energy for lens disassem- 2.94 ␮m, which lies in the infrared spectrum and is bly and removal. Advances in phacoemulsification tech- highly absorbed by water. In water, cavitation bubbles nology and fluidics encouraged this ongoing change in form and collapse instantaneously. However, the col- technique by allowing for greater amounts of vacuum to lapse of the bubbles occurs more slowly in the nuclear be safely used. In addition, power modulations have material of the lens. The laser beam can travel across the allowed for more efficient use of ultrasound energy with first bubble and form a second bubble in line with the greater safety in the delicate intraocular environment.4 first. If a third bubble forms, it increases the effective Elimination of the frictional heat produced during range of the laser to 3.0 mm. Direct concussive effects of ultrasound phacoemulsification and reduction of the the laser energy propagation wave disrupt the lens ma- power required for cataract extraction represent impor- terial, creating an emulsate that is aspirated from the eye. tant steps toward the goal of atraumatic surgery. Laser As mentioned, a principle advantage of laser cataract technology, including the erbium:YAG (Er:YAG) (Pha- extraction in general and of the Er:YAG system in par- colase, Zeiss-Meditec) and neodymium:YAG (Nd: ticular is the absence of thermal energy. Because the tip YAG) such as photon phacolysis (Paradigm) and of the Er:YAG laser system does not produce relevant Dodick photolysis (ARC), offers 1 approach to the elim- heating effects, the risk of corneal burn is eliminated and ination of thermal energy and reduction of power during the potential for reduced incision size is created.5 phacoemulsification. The sonic phacoemulsification The Phacolase Er:YAG laser has variable pulse en- system (Staar Wave, Staar Surgical) is another new ap- ergy from 5 to 50 mJ as well as variable frequency from proach to the elimination of heat and the danger of 10 to 100 Hz. In its present form, the Phacolase system thermal injury to the cornea. Modification of ultra- is coupled to a Megatron irrigation/aspiration (I/A) sound energy through refinement of power modulation pump (Geuder, Heidelberg). The Megatron has a peri- offers yet another route leading to elimination of heat staltic pump with venturi-like effect. The Phacolase and reduction in incision size (WhiteStar, Allergan). handpiece incorporates the laser fiber inside the aspira- The introduction of innovative oscillatory tip motion in tion port. A bidirectional foot switch is used that sepa- coordination with power modulation permits further rates infusion and aspiration from laser energy. Moving reduction of average phaco power and effective phaco the foot pedal laterally increases the repetition rate in a time (NeoSoniX, Alcon). Other new modalities under linear fashion. Pushing the pedal down provides linear investigation, which promise low-energy, nonthermal control of vacuum. cataract extraction, include vortex phacoemulsification One method of nuclear disassembly with the Pha- (Avantix, Bausch & Lomb) and Aqualase (Alcon), a flu- colase involves prechopping the nucleus with a device id-based cataract extraction system. developed by Takayuki Akahoshi, MD. This prechop- per can be used to segment the nucleus before phaco- emulsification with the Phacolase. For denser grades of Erbium:YAG Laser Phacoemulsification nuclei, prechopping reduces the total operating time. Laser phacoemulsification represents an emerging Further evolution of the technique will likely emphasize technology in cataract surgery. Several potential advan- separation of irrigation from aspiration and laser in the J CATARACT REFRACT SURG—VOL 28, JUNE 2002 1055 UPDATE/REVIEW: NEW PHACOEMULSIFICATION TECHNOLOGIES In summary, Er:YAG laser phacoemulsification represents an emerging technology with several promis- ing attributes. These include the reduction of energy required for phacoemulsification, absence of risk for thermal injury, and potential reduction of incision size. Neodymium:YAG Laser Phacoemulsification Figure 1. (Fine) Mean Er:YAG energy in joules by nucleus grade. Dodick Photolysis Dodick6 introduced the pulsed Q-switched Nd: YAG laser in 1991. The FDA has approved the laser for cataract extraction. This 1064 nm Nd:YAG laser system uses plasma formation and shock-wave generation to produce photolysis of lens material. The shock wave results from the impact of laser radiation on a titanium plate. Alzner and Grabner7 have shown that there is no heat production at the laser tip. As with the other non- thermal modalities discussed here, the Nd:YAG laser Figure 2. (Fine) Time required for Er:YAG phacoemulsification as does not require a cooling sleeve and therefore permits compared
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