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APRIL 25, 2014
This OCULAR SURGERY NEWS spotlight is
produced by SLACK Incorporated and
sponsored as an educational service
by Alcon Laboratories, Inc.
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OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Introduction
The achievement of high patient satisfaction
with cataract refractive surgery requires achieving an accurate target refractive outcome goal.
And as reimbursement rates for cataract surgery
continue to decline, ophthalmologists are seeking alternative models of reimbursement, such
as patient-pay models. However, to achieve this
goal, ophthalmologists must improve patient
outcomes and satisfaction.
This OCULAR SURGERY NEWS spotlight supplement
is based on a live event presented at OSN New
York 2013, the content of which was created by
the sponsor, Alcon Laboratories, Inc. A panel
of expert faculty discussed innovations for the
modern cataract refractive suite, and this spotlight addresses how these innovations can improve surgical techniques and patient outcomes.
I would like to thank the faculty members for
their participation and Alcon Laboratories, Inc.,
for sponsoring this supplement. For more educational activities on this topic, visit Healio.com/
Ophthalmology/Education-Lab.
Richard L. Lindstrom, MD
Chief Medical Editor
OCULAR SURGERY NEWS
TABLE OF CONTENTS
A process-focused approach to cataract refractive surgery ......................................3
Stephen G. Slade, MD
Femtosecond laser–assisted cataract surgery improves patient outcomes ...........6
Michael P. Jones, MD
Visualization key for ensuring surgical success ..........................................................10
Jack M. Chapman Jr., MD
Phaco advancements streamline cataract removal ...................................................12
Richard J. Mackool, MD
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
© Copyright 2014, SLACK Incorporated. All rights reserved. No part of this publication may be reproduced without written permission. The ideas and opinions expressed in this OCULAR SURGERY
NEWS® supplement do not necessarily reflect those of the editor, the editorial board or the publisher, and in no way imply endorsement by the editor, the editorial board or the publisher.
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
A process-focused approach to
cataract refractive surgery
Stephen G. Slade, MD
Ophthalmologists are currently facing challenges with
declining reimbursement rates
resulting from single-payer
reimbursement models and a
13.6% Medicare physician fee
cut for cataract surgery.1 To
avoid this lockstep relationship
with single-payer reimburseStephen G. Slade
ment, ophthalmologists should
explore a patient-pay model and offer patients value
through elective, non-insured procedures that they
will be willing to pay for out of pocket. The way to
create that value is by improving patient outcomes
and satisfaction. For example, approximately 95% of
patients who undergo LASIK, which is a patient-pay
procedure, are satisfied with the results.2
Patient satisfaction following cataract and refractive surgeries largely depends on a surgeon hitting the refractive target.3 Although this outcome is
currently not as successful for cataract surgery as it
is for LASIK, there lies an opportunity. Advanced
technology IOLs represent a significant value proposition for patients,4 but they have to be a true value.
The science must improve, and the technology must
enable improved cataract outcomes that are comparable to those achieved by LASIK. Several sources of
variability associated with cataract surgery should
be addressed, such as selecting the appropriate IOL,
determining the spherical component of the IOL
properly, planning the astigmatism management
and configuring alignment. The cataract removal
process also must be optimized.5 All of these aspects
must be addressed to improve outcomes and establish a successful patient-pay model in which the patient will become an advocate for these services. A
new package of innovative, compatible technologies
is now available that provides a platform to advance
and digitize cataract surgery.
The modern refractive cataract suite
The cataract refractive suite by Alcon Laboratories, Inc. (Fort Worth, Texas) consists of innovative
technologies for every phase of the procedure,
which are designed to improve efficiency, optimize
patient outcomes and specifically address better
patient satisfaction. The suite includes the LenSx
Laser, a fully integrated, image-guided femtosecond laser designed specifically for laser cataract
refractive surgery; the LuxOR Microscope, which
provides guidance and advanced illumination; and
the Centurion Vision System, which digitally optimizes the cataract removal process.
The Verion Image Guided System (Alcon Laboratories, Inc.) is compatible with the LenSx Laser,
LuxOR Microscope and Centurion Vision System
and enables these devices to work with one another
(Figure 1, page 4). Currently used in six practices in
the United States and several outside of the United
“The cataract refractive suite by Alcon
Laboratories, Inc. (Fort Worth, Texas) consists
of innovative technologies for every phase of
the procedure, which are designed to improve
efficiency, optimize patient outcomes and
specifically address better patient satisfaction.”
— STEPHEN G. SLADE, MD
States, the Verion system is designed to enhance accuracy and efficiency throughout the stages of the
cataract refractive process, from surgical planning
to execution. The goal is to use a single reference
image of a patient among all of the devices while
guiding and planning the patient’s treatment, as
well as performing the treatment and tracking outcomes. It is a way to help standardize outcomes and
reduce variability.
The Verion Image Guided System
The Verion Image Guided System consists of the
Verion Reference Unit and the Verion Digital Marker. The Reference Unit has a convenient desktop
interface that measures keratometry, pupillometry
and other critical preoperative parameters, captures
a high-resolution diagnostic reference image of
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
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OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Figure 1: The Verion Digital Marker can be used with the LenSx Laser (left) and LuxOR Ophthalmic Microscope (right).
Source: Alcon Laboratories, Inc.
the patient’s eye and auto-detects sclera vessels
and limbus, pupil and iris features.
The Reference Unit also improves surgical planning because it can calculate multiple advanced
IOL formulas, including lens and power selection,
and allows customized incision and implantation
axis planning for each patient. The reference image
of a patient’s eye can also be saved on a USB flash
drive and input directly into the LenSx Laser in the
operating room. It is nondisruptive to the surgeon
and uses the same reference image throughout the
system. The surgeon can then determine all of the
parameters of the surgery and choose the mode
that will be displayed in the surgery during the
guiding stage.
The Verion Digital Marker displays patient information and images from the Reference Unit to
facilitate incision and IOL alignment (Figure 2).
The system features a tracking overlay that aligns
all incisions and IOLs in real time, automatically
compensates for cyclorotation, eliminates the need
for manual eye markings, registers the patient for
accurate centering and alignment of multifocal
and toric IOLS and allows documentation of data
to optimize procedures over time.
I particularly appreciate the robustness of the
Verion system. Once the surgeon brings the patient into the operating room, the Verion system
rapidly recognizes the eye from the picture taken
by the Reference Unit and offers a variety of overlays. The surgeon can have a centration overlay or
an astigmatism overlay, and an overlay that shows
where the surgeon chose to put any primary and
secondary incisions and arcuate cuts. Also, the surgeon can toggle through these overlays with his or
her foot, so it does not slow or disrupt surgery.
The Digital Marker also has a simple display
screen on a stand that can be easily manipulated
using only a couple of buttons. Using it does not
Figure 2: The Verion Digital Marker is designed to
facilitate incision and IOL alignment.
Source: Alcon Laboratories, Inc.
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
require an extra staff person in the operating room
and takes up little time (Figure 2).
The Verion Image Guided System has been an
enjoyable system to use for my colleagues and me.
It provides a reference unit that automatically integrates measurement data into the surgical plan,
eliminating the potential for transcription errors,
uses a single source image throughout the entire
cataract refractive process that tracks the patient
and reduces variability and assists with centration and alignment for implanting advanced
technology IOLs.
References:
1.
Ngoei E. Facing the challenges of stinging cuts.
Ophthalmology Business. April 2013:6-7.
2.
Solomon K et al. LASIK world literature review: quality
of life and patient satisfaction. Ophthalmology.
2009;16(4):691-701.
3.
Devgan U. Achieving refractive accuracy improves
patient satisfaction after cataract surgery. Ocular
Surgery News. February 25, 2011. Available at: http://
www.healio.com/ophthalmology/cataract-surgery/
news/print/ocular-surgery-news/%7Bb035b7a4-53264532-959e-785b4e48334e%7D/achieving-refractiveaccuracy-improves-patient-satisfaction-after-cataractsurgery. Accessed October 2, 2013.
4.
Lindstrom RL. Refractive outcome of toric IOLs
determines patient satisfaction. Ocular Surgery News.
August 10, 2009. Available at: http://www.healio.
com/ophthalmology/refractive-surgery/news/print/
ocular-surger y-news/%7B523aeb66-1929-49b1823a-a56bf6dfc836%7D/refractive - outcome - oftoric-iols-determines-patient-satisfaction. Accessed
October 2, 2013.
5.
Vasta S. Refractive outcome is main ingredient
for premium IOL success. Premier Surgeon. March/
April 2010. Available at: http://www.healio.com/
ophthalmology/cataract-surger y/news/print/
premier-surgeon/%7Bf856fcb3-6144-4ac1-90ffb4ee61d354f1%7D/refractive -outcome -is-mainingredient-for-premium-iol-success. Accessed
October 2, 2013.
Stephen G. Slade, MD, is a surgeon at Slade and Baker
Vision in Houston. Dr. Slade is a paid consultant for Alcon
Laboratories, Inc.
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
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Femtosecond laser–assisted cataract
surgery improves patient outcomes
Michael P. Jones, MD
Patient expectations of cataract surgery have changed,
with most patients now seeking LASIK-type results. However, it is difficult to obtain
those results without the accuracy of a femtosecond laser.
Femtosecond laser – assisted
cataract surgery has been
Michael P. Jones
demonstrated to improve patient outcomes, mitigate the risk for complications
and reduce phacoemulsification power and time.1
One such femtosecond laser is the LenSx Laser
(Alcon Laboratories, Inc.), an image-guided device designed specifically for laser refractive cataract surgery. It uses a surgical platform that allows
surgeons to visualize, customize and perform the
most challenging steps of cataract surgery. The
LenSx Laser was the first of its kind, and Alcon’s
platform design enables continued innovation and
rapid enhancements.
Fully upgradable architecture
Current LenSx Software offers improved visualization and high-definition optical coherence
tomography (Figure 1), which makes a significant
difference when identifying anatomy and structures during the procedure before phacoemulsification. In addition to being easy to use and operate, the LenSx Laser provides many opportunities
for precise and reproducible steps, especially with
capsulorrhexis and incisions. It is difficult to
achieve by hand the level of customization and accuracy that a laser can provide.
A previous improvement of the LenSx Laser
was the enhanced SoftFit Patient Interface. It uses a
soft, modified silicone hydrogel lens insert, which
allows easier docking, particularly when it comes
to alignment of the globe. It also uses a smaller
patient interface, down from 22 mm to 19.8 mm,
which is advantageous for patients with small
eyes. With the development of the SoftFit Patient
Interface, there also has been an increase in the
number of free-floating capsulotomies,2 and, in my
Figure 1: The early (top) and subsequent (middle)
versions of the LenSx software improved visualization.
The latest version (bottom) offers even greater
visualization of the lens in high definition.
Source: Alcon Laboratories, Inc.
experience using the Interface, I have experienced
free-floating capsulotomies in nearly every case.
The SoftFit Patient Interface was designed to help
eliminate corneal distortion in nearly all cases,
improving centration and docking, and delivers
only 16 mm Hg of IOP rise when it is docked with
the eye.
These advancements, which resulted from
user-generated suggestions, have led to improved
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Figure 2: The hybrid laser pattern is a combination of
cylinder and chop patterns and permits more rapid lens
removal. The number of cuts is customizable.
Figure 3: The fragmentation laser pattern will soon
be available. It permits both horizontal and vertical
segments, and the size of cubes is customizable.
Source: Alcon Laboratories, Inc.
Source: Alcon Laboratories, Inc.
surgical performance, especially compared with
the previous versions of the laser. Less energy is required during each treatment, and procedure time
is reduced. My colleagues and I can get the patient
docked, treated and into the operating room to finish surgery in fewer than 90 seconds.
Software version 2.23 is the latest advancement in
the LenSx Laser platform. Released at the American
Academy of Ophthalmology 2013 Annual Meeting, the LenSx Laser 2.23 software update includes
three key features: new fragmentation patterns,
advanced automation features and compatibility
with the Verion Image Guided System.
LenSx SoftFit
Patient Interface
•
•
•
•
•
•
Improves high definition OCT
imaging
Eliminates corneal distortion in
nearly all cases
Improves docking and centration
Lowers IOP compared to former
patient interface
Reduces energy required for
phacoemulsifcation
No liquid interface required
Fragmentation patterns
The LenSx Laser offers various laser fragmentation patterns that allow the surgeon to customize fragmentation to a pattern that best suits both
the surgeon and the patient. I use the all-cylinder
pattern for a patient who has a softer lens, because
the number of cylinders is customizable. I use the
straight chop pattern for patients who have harder
nuclei, as the number of cuts is also customizable.
I frequently use the hybrid pattern, a combination
of chop and cylinder patterns (Figure 2).
A fourth pattern, fragmentation, will soon
be made available for use with the LenSx Laser
(Figure 3). The additional fragmentation pattern
is a matrix-like design that separates the nucleus
into custom-sized cubes and permits both horizontal and vertical segments. The surgeon determines the size of the cubes. I like the ability to split
the cataract anywhere or along any axis with this
new pattern. The combination of linear and radial
incisions enhances lens removal and increases efficiency in my experience.
Advanced automation features
The latest software enables pre-positioning of
incisions through automated recognition of the
limbus. The LenSx Laser automated placement
of primary, secondary and arcuate incisions and
pre-positioning of the capsulotomy has reduced
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
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OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Comparison of Phaco Powers
50.0
p = 0.001
*
50.0
p = 0.01
45.0
40.0
40.0
35.0
35.0
30.0
25.0
20.0
30.0
p = 0.001
p = 0.03
*
*
p = 0.01
*
25.0
20.0
15.0
15.0
10.0
10.0
5.0
5.0
0.0
0.0
CDE
Manual
Power (%)
Energy (CDE)
45.0
*
U/S total
equiv
power in
position
#3
Avg
phaco
power
Avg
phaco
power in
position
#3
Avg
torsional
amp
Avg
torsional
amp in
position
#3
Equiv avg
torsional
amp in
position
#3
LenSx® Laser
Phaco Parameters
Figure 4: Residents using the LenSx Laser experienced significantly lower cumulative dissipated energy, less ultrasound
power and less torsional amplitude.
Source: de la Cruz J. A reduction in the femtosecond cataract learning curve: Initial resident experience performing cataract surgery
with and without femtosecond laser. FP-2989. Presented at: XXXI Congress of the ESCRS; October 8, 2013; Amsterdam.
procedure time by 10 to 15 seconds in my experience. The new software automatically assists with
centration and focus. The pattern also has the
ability to automatically align capsulotomy bars and
the depth of the chop pattern in real time.
“...use of the LenSx Laser reduces phaco power
and phaco time, decreases CDE during cataract
extraction and results in fewer complications.”
— MICHAEL P. JONES, MD
The Verion Image Guided System
The LenSx Laser can also be used in conjunction with the Verion Image Guided System (Alcon
Laboratories, Inc.), which enables more efficient
surgical planning. The Verion Image Guided system uses a surgeon’s customized and predetermined surgical plan, registers the patient’s eye
based on a previously taken reference image,
which eliminates the need to preoperatively and
intraoperatively mark the eye, and compensates
for cyclorotation.
Resident experience with the LenSx Laser
Data that were recently presented at the XXXI
Congress of European Society of Cataract and
Refractive Surgeons in Amsterdam compared
resident surgeons’ experience performing cataract surgery with a femtosecond laser vs. standard manual cut cataract surgery.1 Residents at
the University of Illinois Eye and Ear Infirmary
performed laser-assisted cataract surgery using
the LenSx Laser on 55 eyes and standard phaco
techniques without a laser on 107 eyes. Within
the laser group, the LenSx laser was also used to
create corneal incisions in 52 of the 55 eyes, lens
fragmentation in 54 of the 55 eyes and anterior
capsulotomy in all 55 eyes. In the standard phaco
group, these steps were performed manually with
traditional phaco.
The laser-assisted surgery resulted in reduced
phaco power, cumulative dissipated energy
(CDE), ultrasound power, complications and torsional amplitude compared with the manual cut
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
cataract surgeries (Figure 4). The residents also
experienced significantly less fluid usage in the
eye when using the LenSx Laser. The residents
saw four posterior capsular tears in the manual
surgery group compared with zero tears in the
LenSx Laser group and thermal burn effect in one
of the 107 manual cases compared with zero in
the LenSx Laser group.
These data show that use of the LenSx Laser
reduces phaco power and phaco time, decreases
CDE during cataract extraction and results in fewer complications. The LenSx Laser, which is currently in use in 61 countries by more than 2,200
surgeons, has been used in more than 150,000
procedures. The technology has been well tested
and proven effective for cataract surgery.
References:
1.
de la Cruz J. A reduction in the femtosecond cataract
learning curve: Initial resident experience performing
cataract surgery with and without femtosecond laser.
FP-2989. Presented at: XXXI Congress of the ESCRS;
October 8, 2013; Amsterdam.
2.
Alcon data on file.
Michael P. Jones, MD, is the managing partner at
Illinois Eye Surgeons and assistant professor at St. Louis
University Eye Institute. He is a paid consultant for Alcon
Laboratories, Inc.
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
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Visualization key for ensuring
surgical success
Jack M. Chapman Jr., MD
Visualization is a critical
factor when preparing for and
performing ocular surgery. A
surgeon must be able to see the
anatomy of the patient’s eye to
ensure accuracy and efficiency
of the procedure. To avoid the
frustration caused by poor
visualization, surgeons must
Jack M. Chapman Jr.
choose the right tools.
The LuxOR LX3 Ophthalmic Microscope (Alcon
Laboratories, Inc.) is designed for optimal performance and comfort (Figure 1). It combines comprehensive, consistent visualization with easy to use
functionality to deliver superior red reflex stability,
greater depth of focus, improved surgeon experience
and procedure-enhancing upgrades. The LuxOR LX3
Microscope also uses Illumin-i Technology (Alcon
Laboratories, Inc.) to increase visualization through
patented three-beam, collimated nonfocused light
that provides a surgeon with a red reflex zone six
times larger than focused-light microscopes. The red
reflex zone maintains a consistently stable, high-quality red reflex regardless of pupil size, centration, lens
tilt or patient eye movement.
The LuxOR E-71 Microscope
The distinguishing feature of the LuxOR LX3
Microscope is the proprietary position of the objective lens, which is located above the light source.
The positioning creates a focal length that is 60 mm
longer than other microscopes, which allows greater depth, detail recognition and contrast for every
phase of cataract surgery. Placing the objective lens
above the illumination source also allows the light
to reach the eye in a nonfocused format, providing
increased visualization and ensuring that the light
passes through the object only once.
“The distinguishing feature of the
LuxOR LX3 Microscope is the proprietary
position of the objective lens, which
is located above the light source.”
— JACK M. CHAPMAN JR., MD
The LuxOR LX3 Microscope also incorporates the
Libero-XY Communication System (Alcon Laboratories, Inc.), which delivers at-a-glance microscope
feedback to the surgeon. A full-color, touch-screen
monitor and wireless foot pedal allow customization
The Redesigned LuxOR LX3 Ophthalmic Microscope
Figure 1: The LuxOR Ophthalmic Microscope is designed for optimal surgeon comfort and performance.
Source: Alcon Laboratories, Inc.
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Figure 2: The Libero-XY communication system has a
full-color touch screen and at-a-glance access to unique
parameters, such as XY and focus position.
Figure 3: The Verion system eliminates the need to mark
the eye because it automatically registers the patient’s eye.
Source: Alcon Laboratories, Inc.
Source: Alcon Laboratories, Inc.
of preferred settings for efficient preoperative set
up, and settings such as pupillary distance, initial
focus point and magnification level can be saved for
future surgeries (Figure 2). The ergonomics of the
microscope are also advantageous because the main
controls are condensed in one area to minimize disruption for the surgeon. The communication system is located at the top of the microscope where a
surgeon can check focus and the amount of illumination; the handles of the microscope also contain
controls for easier adjustments during surgery.
The microscope also includes the optional QVUE Ophthalmic Microscope (Alcon Laboratories,
Inc.), 3-D assistant visualization upgrade, which features a 180° swivel, an independent magnification
changer and 3-D stereo assistant scope that does not
take light from the surgeon’s optical pathway.
Verion Image Guided System
The LuxOR LX3 Microscope is supported by the
Verion Image Guided System (Alcon Laboratories,
Inc.). This microscope-integrated display incorporates the surgical plan onto the external monitor
and projects it through the oculars.
The Verion system eliminates the necessity to
mark the patient’s eye, because it registers the eye’s
unique pupil, limbus and scleral vessel pattern, and
inaccuracies caused by ink leaching out and being
difficult to visualize are mitigated (Figure 3). Even
after femtosecond laser procedures, it registers the
vessels with ease. The Verion system also tracks and
follows the patient’s eye movements and accounts for
cyclotorsion. The Verion Digital Marker provides a
visual reference of all incisions during capsulotomy.
The system also assists with alignment of toric IOLs
and centration of multifocal IOLs, which can be delivered using the controls on the Centurion Vision
System (Alcon Laboratories, Inc.) foot pedal.
My colleagues and I have used the LuxOR LX3
Microscope for several years, and it has been beneficial to our ambulatory surgical center. One of the
most advantageous aspects of the microscope is the
ability to preprogram the device. When multiple
surgeons use it, the microscope can be preset to
the desired settings of a specific surgeon and saved
for future use. The surgeon just chooses his or her
profile upon entering the operating room, and the
microscope automatically programs the settings.
The wireless foot pedal also improves efficiency in
the operating room because the wire will not disrupt the procedure. The improved visualization and
depth of focus also have been a key benefit when
using this device.
Jack M. Chapman Jr, MD, is a surgeon at Gainesville Eye
Associates in Georgia. Dr. Chapman is a paid consultant for
Alcon Laboratories, Inc.
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
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Phaco advancements streamline
cataract removal
Richard J. Mackool, MD
Phacoemulsification technology continues to evolve, providing the opportunity to increase
surgical efficiency and improve
patient outcomes. These are increasingly critical issues as reimbursement for cataract removal
continues to decrease while the
volume of patients requiring
Richard J. Mackool
cataract surgery increases.
Over the past two decades, Alcon Laboratories,
Inc. (Ft. Worth, Texas), has released three generations of phaco technology. The Legacy was introduced in 1993, and the Infiniti Vision System was
introduced in 2003. Both incorporated fluidics advances, and the Infiniti featured the advent of OZil
torsional technology.
The Centurion Vision System is Alcon’s latest innovation in phacoemulsification (Figure 1).
Centurion sets the standard in anterior chamber
stability, emulsification efficiency and console ergonomics. It is also ready to communicate with
other Alcon Systems, such as the Verion Image
Guided System, to create a seamless flow through
the cataract procedure. The console also features a
wireless footswitch, and console functions can be
remotely controlled.
Controlling infusion pressure
A key difference between the Centurion and
all other phacoemulsification technology is Active
Fluidics Technology. The Active Fluidics system
is not gravity based, ie, it eliminates the hanging
infusion bottle. Within the console of the Centurion is an infusion fluid reservoir that automatically and variably compresses a bag of balanced
salt solution as the system monitors and responds
to changes in infusion pressure, thereby instantaneously increasing or decreasing infusion to maintain target IOP. These advances in detection and
response to variations in pressure throughout the
cataract removal reduce occlusion break surge, enhance fluidics control and are designed to increase
the efficiency and pace of the procedure.
The active fluidics of the Centurion system maintains the volume in the anterior chamber at maximum level, and the surgeon is able to select a firm
globe (higher IOP) or a softer one (lower IOP) as
he or she desires. The system maintains the target
IOP within a much narrower range than an infusion gravity system as it maintains chamber volume
at target levels.
Intelligent phacoemulsification
Alcon’s advancements in phacoemulsification
technology include the OZil Torsional handpiece
in 20061 that has been demonstrated to reduce fluid
consumption and enhance followability by reducing repulsion (chattering). OZil Intelligent Phaco
(IP) software was introduced in 2009 and leverages
the combined benefits of torsional and longitudinal
phaco, reducing undesirable tip occlusion while
maintaining lens material at the shearing plane.
In 2013, along with the Centurion Vision System,
Alcon released the Intrepid Balanced Tip design
(Alcon Laboratories, Inc.), an even more efficient
tip that is designed to maximize energy at the distal end of the needle. Combined with OZil IP, new
software and low friction sleeves, the Balanced Tip
Figure 1: The Centurion Vision System is Alcon’s latest
innovation in phacoemulsification.
Source: Alcon Laboratories, Inc.
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Figure 2: A curved chopper can simplify the chopping
step and stabilize the nucleus.
Figure 3: The AutoSert IOL injector provides consistent
control during IOL insertion.
Source: Mackool RJ
Source: Mackool RJ
and Centurion system permit a range of aspiration rate, vacuum and ultrasonic parameters to be
used under linear control. The Balanced Tip offers
a more efficient alternative to previous tip designs
for torsional phaco by simultaneously enhancing
cutting efficiency, reducing undesirable tip occlusion, improving the thermal profile and reducing
incision “misting.” A unique double-bend design
maximizes torsional tip movement at the distal
end while minimizing movement within the incision. This results in rapid removal of both dense
and soft nuclei.
The Intrepid Infusion Sleeves (Alcon Laboratories, Inc.) include variable wall thickness designed
to reduce friction and maintain positional stability of the sleeve. These features are especially useful
for surgeons who prefer smaller, tighter incisions.
Crestpoint Management, St. Louis). The curved
area conforms to the equatorial lens anatomy,
making it easier to position the chopper, hold the
nucleus steady during sculpting and chop the nucleus after sculpting is completed (Figure 2).
The AutoSert IOL Injector (Alcon Laboratories, Inc.) provides consistent automated control
of IOL delivery (Figure 3). AutoSert permits surgeons to use a single hand on the injector, freeing
the other hand to stabilize the globe. The speed of
the IOL injection is controlled by the Centurion
foot pedal. AutoSert is compatible with Monarch
C and D Cartridges.
Surgical procedure
I prefer to use the Balanced Tip oriented in a
horizontal fashion (tip oriented sideways), with
both infusion portals also horizontally oriented.
The nucleus is deeply sculpted utilizing high magnification until a red reflex is obtained. It is then
chopped either by impaling the nucleus with the
tip at a vacuum of 250 mm Hg to 300 mm Hg if
the lens is relatively dense, or simply utilizing the
tip and the chopper without impaling the nucleus
if it is not dense.
The chopping step can be simplified by using
a curved chopper (Mackool Big Ball Chopper,
Applied integration
The Centurion Vision System is compatible
with other Alcon technologies. These include the
AutoSert IOL Injector, Intrepid Sleeves, LuxOR
Ophthalmic Microscope, Verion Image Guided
System and LenSx Laser. In my experience, the
Centurion Vision System is a great advance in
phacoemulsification technology.
References:
1.
Vasavada AR et al. Comparison of torsional and microburst
longitudinal phacoemulsification: a prospective,
randomized, masked clinical trial. Ophthalmic Surg Lasers
Imaging. 2010;41(1):109-14.
Richard J. Mackool, MD, is medical director of The Mackool
Eye Institute in Astoria, New York. Dr. Mackool is a paid
consultant for Alcon Laboratories, Inc.
Please refer to page 14 for important product information about the Alcon surgical products mentioned in this supplement.
13
14
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
Important Product Information
CENTURION® Vision System Important
Safety Information
can create a hazardous condition that may result
Only trained personnel familiar with the
in patient injury. During any ultrasonic procedure,
process of IOL power calculation and astigmatism
metal particles may result from inadvertent touch-
correction planning should use the VERION™
ing of the ultrasonic tip with a second instrument.
Reference Unit. Poor quality or inadequate bi-
restricts
Another potential source of metal particles result-
ometer measurements will affect the accuracy of
this device to sale by, or on the order of,
ing from any ultrasonic handpiece may be the
surgical plans prepared with the VERION™ Refer-
a physician.
result of ultrasonic energy causing micro abrasion
ence Unit.
Caution:
Federal
(USA)
law
As part of a properly maintained surgical en-
The following contraindications may affect
of the ultrasonic tip.
vironment, it is recommended that a backup IOL
ATTENTION: Refer to the Directions for Use
the proper functioning of the VERION™ Digital
Injector be made available in the event the Auto-
and Operator’s Manual for a complete listing of in-
Marker: changes in a patient’s eye between pre-
Sert® IOL Injector Handpiece does not perform as
dications, warnings, cautions and notes.
operative measurement and surgery, an irregular
elliptic limbus (e.g., due to eye fixation during sur-
expected.
Indication: The CENTURION® Vision system
is indicated for emulsification, separation, irrigation, and aspiration of cataracts, residual cortical
material and lens epithelial cells, vitreous aspiration
VERION™ Image Guided System Important
gery, and bleeding or bloated conjunctiva due to
Safety Information
anesthesia). In addition, the use of eye drops that
CAUTION: Federal (USA) law restricts this
device to sale by, or on the order of, a physician.
constrict sclera vessels before or during surgery
should be avoided.
VERION™
WARNINGS: Only properly trained person-
bipolar coagulation, and intraocular lens injection.
Reference Unit is a preoperative measure-
nel should operate the VERION™ Reference Unit
The AutoSert® IOL Injector Handpiece is intended
ment
and VERION™ Digital Marker.
to deliver qualified AcrySof® intraocular lenses into
a high-resolution reference image of a pa-
the eye following cataract removal.
tient’s
and cutting associated with anterior vitrectomy,
INTENDED
device
eye
USES:
that
in
The
captures
order
to
and
utilizes
determine
Only use the provided medical power sup-
the
plies and data communication cable. The power
The AutoSert® IOL Injector Handpiece
radii and corneal curvature of steep and flat axes,
supplies for the VERION™ Reference Unit and the
achieves the functionality of injection of in-
limbal position and diameter, pupil position and
VERION™ Digital Marker must be uninterruptible.
traocular lenses. The AutoSert® IOL Injector
diameter, and corneal reflex position. In addition,
Do not use these devices in combination with an
Handpiece is indicated for use with the AcrySof®
the VERION™ Reference Unit provides pre-opera-
extension cord. Do not cover any of the component
lenses SN6OWF, SN6AD1, SN6AT3 through
tive surgical planning functions that utilize the ref-
devices while turned on.
SN6AT9, as well as approved AcrySof® lenses
erence image and pre-operative measurements to
Only use a VERION™ USB stick to transfer data.
that are specifically indicated for use with this
assist with planning cataract surgical procedures,
The VERION™ USB stick should only be connected
inserter,
including the number and location of incisions
to the VERION™ Reference Unit, the VERION™
and the appropriate intraocular lens using existing
Digital Marker, and other compatible devices. Do
Appropriate use of CENTU-
formulas. The VERION™ Reference Unit also sup-
not disconnect the VERION™ USB stick from the
RION® Vision System parameters and accessories
ports the export of the high-resolution reference
VERION™ Reference Unit during shutdown of the
is important for successful procedures. Use of low
image, preoperative measurement data, and surgi-
system.
vacuum limits, low flow rates, low bottle heights,
cal plans for use with the VERION™ Digital Marker
The VERION™ Reference Unit uses infrared
high power settings, extended power usage, power
and other compatible devices through the use of a
light. Unless necessary, medical personnel and pa-
usage during occlusion conditions (beeping tones),
USB memory stick.
tients should avoid direct eye exposure to the emit-
as
indicated
in
the
approved
labeling of those lenses.
Warnings:
ted or reflected beam.
failure to sufficiently aspirate viscoelastic prior
The VERION™ Digital Marker links to com-
to using power, excessively tight incisions, and
patible surgical microscopes to display concurrent-
PRECAUTIONS: To ensure the accuracy
combinations of the above actions may result in
ly the reference and microscope images, allowing
of VERION™ Reference Unit measurements, de-
significant temperature increases at incision site
the surgeon to account for lateral and rotational
vice calibration and the reference measurement
and inside the eye, and lead to severe thermal eye
eye movements. In addition, the planned capsu-
should be conducted in dimmed ambient light
tissue damage.
lorhexis position and radius, IOL positioning, and
conditions. Only use the VERION™ Digital
Good clinical practice dictates the testing for
implantation axis from the VERION™ Reference
Marker in conjunction with compatible surgical
adequate irrigation and aspiration flow prior to en-
Unit surgical plan can be overlaid on a computer
microscopes.
tering the eye. Ensure that tubings are not occluded
screen or the physician’s microscope view.
or pinched during any phase of operation.
CONTRAINDICATIONS:
The
ATTENTION: Refer to the user manuals for
following
the VERION™ Reference Unit and the VERION™
The consumables used in conjunction with AL-
conditions may affect the accuracy of surgical
Digital Marker for a complete description of prop-
CON® instrument products constitute a complete
plans prepared with the VERION™ Reference Unit:
er use and maintenance of these devices, as well as
surgical system. Use of consumables and handpieces
a pseudophakic eye, eye fixation problems, a non-
a complete list of contraindications, warnings and
other than those manufactured by Alcon may affect
intact cornea, or an irregular cornea. In addition,
precautions.
system performance and create potential hazards.
patients should refrain from wearing contact lenses
AEs/Complications: Inadvertent actuation
of Prime or Tune while a handpiece is in the eye
during the reference measurement as this may interfere with the accuracy of the measurements.
LenSx Laser® Important Safety Information
Caution: United States Federal Law restricts
15
OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology
this device to sale and use by or on the order of a
•
physician or licensed eye care practitioner.
Indication: The LenSx® Laser is indicated for
use in patients undergoing cataract surgery for re-
This device is not intended for use in
Injector Handpiece is intended to deliver qualified
pediatric surgery.
AcrySof® intraocular lenses into the eye follow-
Warnings: The LenSx® Laser System should
only be operated by a physician trained in its use.
ing cataract removal.
The following system modalities additionally
moval of the crystalline lens. Intended uses in cata-
The LenSx® Laser delivery system employs
ract surgery include anterior capsulotomy, phaco-
one sterile disposable LenSx® Laser Patient Inter-
fragmentation, and the creation of single plane and
face consisting of an applanation lens and suction
multi-plane arc cuts/incisions in the cornea, each
ring. The Patient Interface is intended for single
– The INTREPID® AutoSert® IOL Injector
of which may be performed either individually or
use only. The disposables used in conjunction with
Handpiece achieves the functionality of injection
consecutively during the same procedure.
support the described indications:
– Ultrasound with UltraChopper® Tip
achieves the functionality of cataract separation.
ALCON® instrument products constitute a com-
of intraocular lenses.
Restrictions:
plete surgical system. Use of disposables other than
Sert® IOL Injector Handpiece is indicated for
•
Patients must be able to lie flat and mo-
those manufactured by ALCON may affect system
use with AcrySof® lenses SN60WF, SN6AD1,
tionless in a supine position.
performance and create potential hazards.
SN6AT3 through SN6AT9, as well as approved
•
•
•
Patient must be able to understand and
The INTREPID® Auto-
The physician should base patient selection
AcrySof® lenses that are specifically indicated for
give an informed consent.
criteria on professional experience, published lit-
use with this inserter, as indicated in the approved
Patients must be able to tolerate local or
erature, and educational courses. Adult patients
labeling of those lenses.
topical anesthesia.
should be scheduled to undergo cataract extrac-
Patients with elevated IOP should use
tion.
Warnings: Appropriate use of INFINITI®
Vision System parameters and accessories is im-
topical steroids only under close medical
Precautions:
portant for successful procedures. Use of low
supervision.
•
Do not use cell phones or pagers of any
vacuum limits, low flow rates, low bottle heights,
Contraindications:
kind in the same room as the LenSx®
high power settings, extended power usage, power
•
Laser.
usage during occlusion conditions (beeping tones),
Corneal disease that precludes applanation of the cornea or transmission of
•
Discard used Patient Interfaces as
failure to sufficiently aspirate viscoelastic prior
medical waste.
to using power, excessively tight incisions, and
Descemetocele with impending cor-
AEs/Complications:
combinations of the above actions may result in
neal rupture.
•
Capsulotomy, phacofragmentation, or
significant temperature increases at incision site
cut or incision decentration
and inside the eye, and lead to severe thermal eye
Incomplete or interrupted capsuloto-
tissue damage.
laser light at 1030 nm wavelength.
•
•
Presence of blood or other material in
the anterior chamber
•
•
•
•
Poorly dilating pupil, such that the iris
my, fragmentation, or corneal incision
is not peripheral to the intended diam-
procedure
above the preset values, or lowering the IV pole
eter for the capsulotomy.
•
Capsular tear
below the preset values, may cause chamber shal-
Conditions which would cause inad-
•
Corneal abrasion or defect
lowing or collapse which may result in patient
equate clearance between the intended
•
Pain
injury.
capsulotomy depth and the endothe-
•
Infection
When filling handpiece test chamber, if
lium (applicable to capsulotomy only)
•
Bleeding
stream of fluid is weak or absent, good fluidics
Previous corneal incisions that might
•
Damage to intraocular structures
response will be jeopardized. Good clinical prac-
provide a potential space into which
•
Anterior chamber fluid leakage, ante-
tice dictates the testing for adequate irrigation and
rior chamber collapse
aspiration flow prior to entering the eye.
the gas produced by the procedure can
•
•
escape.
•
Corneal thickness requirements that
Attention: Refer to the LenSx® Laser Opera-
Elevated pressure to the eye
are beyond the range of the system.
tor’s Manual for a complete listing of indications,
Corneal opacity that would interfere
warnings and precautions.
with the laser beam.
•
•
•
•
Adjusting aspiration rates or vacuum limits
Ensure that tubings are not occluded or
pinched during any phase of operation.
AEs/Complications: Use of the INFINITI®
Vision System handpieces in the absence of irrigation flow and/or in the presence of reduced or lost
Hypotony or the presence of a corneal
INFINITI® Vision System
aspiration flow can cause excessive heating and
implant.
Caution: Federal law restricts this device to
potential thermal injury to adjacent eye tissues.
Residual, recurrent, active ocular or
sale by, or on the order of, a physician.
eyelid disease, including any corneal
Indication: The INFINITI® Vision System
abnormality (for example, recurrent
is indicated for emulsification, separation, and
corneal
removal of cataracts, the removal of residual cor-
erosion,
severe
basement
membrane disease).
tical material and lens epithelial cells, vitreous
History of lens or zonular instability.
aspiration and cutting associated with anterior
Any contraindication to cataract or
vitrectomy, bipolar coagulation, and intra-ocular
keratoplasty.
lens injection. The INTREPID® AutoSert® IOL
ATTENTION: Refer to the directions for use
for a complete listing of indications, warnings and
precautions.
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