Case#2: Innovative Phacoemulsification Technologies that Prevent Post-occlusion Surge

EP: 1.Case #1: Post-occlusion Surge

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EP: 2.Case#2: Innovative Phacoemulsification Technologies that Prevent Post-occlusion Surge

EP: 3.Surgical Pearls for Phacoemulsification

I. Paul Singh, MD: Here's our second case. At the end of the day, we want nice stable chambers, but how do we mitigate things like postocclusion surge? Well, we have different technologies at our disposal. One technology is being able to know how much fluid is leaving the eye and using what we call pressurized infusion [available on Centurion Vision System (Alcon), Stellaris (Bausch+Lomb)]. Having the phaco machine put more infusion, more irrigation pressurizing your irrigation to allow the eye pressure to be higher, knowing that when we have that break, the actual chamber will not shallow quite as much. So, keep the chambers stable; it's called pressurized infusion using a vacuum based system, as well. Here's a video showing us what that looks like in real time. This is a patient, and again, I do a lot of small pupils; people with hyperopia flow max, all that exfoliation, all those tough cases. What's nice about vacuum-based systems in general is it allows us to control those nuclear pieces; we can stay in the middle of the eye. What I want to show you about this case is that we're not seeing, again, this is a small-pupil flow max patient, where you think, “maybe I should have used iris hooks or some pupil expansion devices,” but I'm able to stay in the middle of the eye and not have to worry as much about the pupil coming down. It's not getting bigger, but it's staying stable. The chamber is stable, I'm not seeing that bouncing. That's what I mean by chamber stability. I'm able to stay in the middle of the eye and use vacuum to bring them nuclear pieces to me. In fact, I took my second instrument out and I'm just slowly letting that nuclear piece come to me. I'm only using bursts of energy, what we call a multiburst mode, and that basically means that as I go down to the foot pedal, I'm only increasing the on time, I'm not increasing the power of phaco. I can slowly get those pieces to come out with very little phaco energy. You can see how I'm in the middle of the eye the entire time, that to me is so important. Even that small piece just came to me. Even with irrigation aspiration, I'm staying close to the border of the anterior capsule, so that way I can see my tip at all times. When you have smaller pupils, you don't want to go underneath the iris and not know where you are. When you can't see the tip, that's when you start to grab things that are not ideal as well. So here I'm staying in the middle of the eye, able to take those cortical fibers out without having to lose my view of that tip. That's vacuum-based system is something called adaptive fluidics.

Another technology that just came out not too long ago is something called synchronized fluid exchange [available on Zeiss Quatera 700], which is another way to keep that chamber stable. What this is doing is independently controlling vacuum as well as irrigation of fluidic. It has independent, kind of like a quad-pump technology they call it. It is allowing us to do thatat relatively lower pressures and still maintain a stable chamber, and go to high vacuum levels. Again, not worrying quite as much about those bouncing chambers. Here's an example of that technology. Here, I'm showing you a patient where the pupil is a little bigger, but again a Flomax patient, hyperopic eyes, the tougher cases. You can see here where, because this can independently control vacuum and fluidics, I'm using the vacuum based nature of it to keep my phaco tip in the middle. Look on the top there, you're going to see my vacuum going to 70, 680; high vacuum, but the chambers stable. I'm not seeing that bouncing of the iris. I can take my second instrument out and stay in the middle of the eye. Let those nuclear pieces come to me, that is important. From a safety point, that's where the eye is deepest. That's where you have furthest depth from the cornea and the capsule. Even in irrigation aspiration, I'm staying in the middle of the eye, closer to the edge of the anterior capsule. Not worrying about going underneath the iris as much. These are some of the benefits of these newer technologies allowing us to keep stable chambers using less amount of fluid, a lot of times less pressure, but going to high vacuum where we can get more efficiency. That's the bottom line, increasing efficiency, and maintaining high safety. I think we're seeing some great technologies out there that allow us to do that. Hope that helps.

Transcript Edited for Clarity