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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. 2 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. 3 4 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. 5 6 OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology 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. 7 8 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. 9 10 OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology 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. 11 12 OCULAR SURGERY NEWS US EDITION | APRIL 25, 2014 | Healio.com/Ophthalmology 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. Delivering the best in health care information and education worldwide 6900 Grove Road, Thorofare, NJ 08086 USA phone: 856-848-1000 • fax: 856-848-6091 • slackinc.com • Healio.com/Ophthalmology This OCULAR SURGERY NEWS supplement is produced by SLACK Incorporated and sponsored as an educational service by Alcon Laboratories, Inc. MIX13464JS