In practice: Integrating a new I/A handpiece for femtocataract surgery

January 1, 2015

A disposable irrigation/aspiration handpiece is designed for the soft removal of cataracts following femtosecond laser fragmentation without the use of ultrasound energy. Dee Stephenson, MD, shares personal experiences with the integration of this technology into practice.

Take home

A disposable irrigation/aspiration handpiece is designed for the soft removal of cataracts following femtosecond laser fragmentation without the use of ultrasound energy. Dee Stephenson, MD, shares personal experiences with the integration of this technology into practice.

 

By Michelle Dalton, ELS; Reviewed by Dee Stephenson, MD

Venice, FL-New technologies-such as the femtosecond laser for cataract surgery-demand new instrumentation and “rethinking the most efficient and safest way to attain the safest surgery and best outcomes for the patient,” said Dee Stephenson, MD, Stephenson Eye Associates, Venice, FL.

“[Surgeons] have to find the balance between femto power and phaco power," noted Dr. Stephenson, when considering the integration of femto-cataract surgery into practice. "We need to know the total amount of energy that goes in the eye in order to do the safest procedure.”

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She quickly realized numerous (but minor) changes to her surgical technique would be needed, including the primary incision size and architecture, the side port incision, the size of her capsulotomy, determining which fragmentation pattern would be best, and needing new instruments (such as a sideport chopper, a zero phaco handpiece) that are specifically designed to work with the new system.

Dr. Stephenson uses the LensAR femtosecond laser, the Stellaris (Bausch + Lomb), and the ZeroPhaco I/A handpiece (Bausch + Lomb).

Handpiece details

The disposable I/A handpiece, with either 15° or 30° bevel needle, is designed for the removal of soft cataracts 1-2+ following femtosecond laser fragmentation without the use of ultrasonic energy, Dr. Stephenson said.

 

Pre-assembled with a standard infusion sleeve, the coaxial handpiece is designed to work with the Stellaris and Stellaris PC systems for lens removal using an I/A mode. The handpiece is used as replacement for the ultrasound phacoemulsification handpiece and is green-colored to avoid confusion with the I/A handpiece for cortical cleanup. In addition to the standard incision 2.4 mm, the ZeroPhaco I/A handpiece is also available for use in a microincisional cataract surgery 2.2mm incision, noted Bausch + Lomb in a prepared statement on the device.

The company has made a “really nice silicone tip I/A-the capsule guard-that you can use without worrying if it touches the posterior capsule,” Dr. Stephenson said. “Because the Stellaris has such great fluidics and chamber maintenance, you're in control the whole time, you can really utilize these micro-incisional instruments to do your micro-incisional surgery (MICS).”

Altered settings

Dr. Stephenson recommends setting the Stellaris to between 300 and 600 mm Hg for vacuum, with a bottle height of 140 cm.

“I prefer pressurized infusion of 50 cm of bottle height and an air pressure of 70 mm Hg,” she said.

In her hands, Dr. Stephenson has “found chamber stability to be excellent, even in high vacuum settings,” she said. Additionally, corneal clarity is similar to standard ultrasound phaco, there is good control of the fragmented lens during aspiration, and “testing which femto fragmentation pattern is best is highly recommended,” she said. Currently, she prefers to use a dice pattern, followed by a cross pattern that still allows her to do a divide and conquer technique.

 

“With the femto, we’re trying to make the nucleus softer so we can just aspirate it,” she said. “It would be nice to find a happy medium to be able to utilize the energy in the most efficient way in both of those techniques.

“You have a learning curve with the femto laser, just like you do with any new technology," Dr. Stephenson said. "What I found in my transition to femto cataract surgery is to try and conquer one thing at a time. I first concentrated on my capsulotomy size and that I had a free floating capsule. Then I learned how to fragment the lens and what pattern was best in my hands."

Using a femtosecond laser also means the instruments feel different in the eye, “and once you learn those things then you can start to do the finesse. You can't do it all at once,” she said.

 “I still hydro-dissect, and hydro-delineate, but I do it much slower,” she said. “I’ll watch the fluid wave and I kind of rotate the lens to release the gas so that my visualization is better.”

She adds, “what I've been doing is using the ZeroPhaco hand piece after fragmentation. The tip is not sharp, so I find aspiration easy. I use my chopper to feed the cubes to the port,” she said, noting she appreciates the varied sizes (one tip is designed for a 2.2 mm incision, another for a 2.4 mm incision).

Dr. Stephenson said the ability to switch from a standard cataract incision to a MICS incision is a benefit to having two different size tips.

“It works great on softer cataract grades 1-2.5, but once you’re dealing with a grade 3 or 4, the ZeroPhaco handpiece may not work as well and you may spend more time in the eye than you realize, and you’re using more fluid. The fluid is causing turbulence and this is energy. You may want to just use the standard phaco handpiece for the dense cataracts,” she said. “With any new technology comes evolution of better and more efficient instruments and techniques. I believe in time we will only need aspiration for any grade of cataract.”

 

 

Dee Stephenson, MD

E: eyedrdee@aol.com

Dr. Stephenson is a consultant to Bausch + Lomb.