Phaco experience maximized
Platform provides attractability, holdability, cutting ability, and followability, surgeon says
New York—Phacoemulsification technology has advanced steadily in the past decade, and the major phaco platforms available in the United States all are refined, highly efficacious systems. Major evolutionary trends in recent years have included improved power modulations, enhanced behind-the-scenes fluidic sensors and safety controls, and the move to smaller incision size.
A significant advancement has been the introduction of non-longitudinal phaco with the development of torsional ultrasound and transversal ultrasound. With torsional ultrasound, the phaco tip oscillates side-to-side on a bent Kelman needle; whereas in transversal ultrasound, the needle travels in an elliptical motion composed of side-to-side and blended longitudinal movement. These power modulations dramatically decrease nuclear repulsion and heat production, enabling the use of lower and safer fluidics and diminishing thermal injury.
If there is one downside to non-longitudinal phaco, it’s the propensity to slow down or clog up with denser nuclei. The introduction of enhanced technology (Ellips FX handpieces and 2.0 software upgrade) for a proprietary phaco platform (Whitestar Signature, Abbott Medical Optics [AMO]) is one option available to eradicate the clogging and maximize the smooth, non-repellant, cutting of transversal ultrasound. Coupled with the ability to choose peristaltic or newly enhanced venturi fluidics (Fusion Fluidics) in each sub-mode, the entire phaco experience is optimized.
Cutting ability
Phaco manufacturers have learned a lot about optimizing side-to-side or horizontal phacoemulsification since its introduction.
AMO’s enhancements with its Ellips FX handpieces are dramatically improved over its original Ellips 1.0. Cutting ability has been increased by significantly increasing the stroke path of the needle, as well as the frequency of its oscillations. The result is a smooth, powerful phaco with the benefits of side-to-side phaco and the cutting ability of longitudinal phaco. Furthermore, these benefits all are attained with a straight phaco tip.
In the first version of Ellips, frequently a Whitestar hyperpulse setting was overlaid on the transversal ultrasound—with the thought that the two technologies would be additive.
In my experience, the hyperpulse pauses (designed to minimize repulsion in longitudinal ultrasound) only slow the already non-repulsive, side-to-side phaco—so I utilize the new technology in continuous mode, again with great cutting effect even on brunescent lenses.
The new technology also achieves two important phaco attributes: holdability and followability. Followability frequently is alluded to in describing phaco and represents the ability of cataract segments to be regrasped fluidly and emulsified, one after another. Followability was much discussed with the introduction of Whitestar or hyperpulse technology several years back, but is improved even further with the latest technology.
Just as important, holdability, or the lack of nuclear chatter at the tip, has been harder to eradicate with longitudinal ultrasound even with high vacuum levels. This is where the new technology also shines—the optimized elliptical movement so effectively minimizes repulsion that I have yet to experience any chatter with its use. Even dense lens fragments stick to the tip without a shimmer. With less chatter comes less endothelial cell loss and clearer corneas.
Furthermore, with such natural holdability, I have been able to reduce significantly my vacuum settings without loss of efficiency.
The new venturi
As a current user of both venturi and peristaltic pumps on multiple phaco platforms, I always have favored the dynamics of venturi fluidics. Without becoming too technical, a venturi pump achieves vacuum before occlusion, whereas a peristaltic pump requires occlusion to generate vacuum.
One of the main benefits of venturi technology is “attractability”—the ability to draw nuclear pieces to the tip without having to bring the tip into full occlusion. Venturi technology has received a bad rap in the past for being unsafe or too fast during phaco, but recent venturi platforms are far safer than their predecessors.
This phaco platform combines venturi fluidics with non-longitudinal ultrasound. By doing so, the new technology has elevated the efficacy and safety of venturi to a new level.
In the past, venturi was employed frequently at high vacuum levels up to 500 mm Hg. This was necessary to overcome the natural repulsion forces of longitudinal phaco, but brought with it an increased risk of post-occlusion surge when not perfectly operated.
With the non-repulsive nature of the new technology, I am able to achieve excellent attractability, as well as holdability, and followability all with maximum vacuum of 200 mm Hg.
There also is a software ability to adjust the ramp-up time, allowing for all the benefits of venturi technology without the pitfalls. The optional addition of dual-linear foot pedal control grants even further control of vacuum for the advanced surgeon.
Transition from peristaltic to venturi
The new technology is so customizable that any surgeon transitioning from peristaltic to venturi technology can do so in steps. For example, venturi technology is superior to peristaltic in I/A mode, and can be tried there first.
Since occlusion is not necessary for vacuum build-up, even small wisps of cortex are drawn in without the chance of occluding with capsule. In epinucleus mode, the strong attractability forces of venturi technology allow for the epinuclear shell to be drawn centrally without requiring peripheral tip placement.
Once surgeons are comfortable with venturi technology in epinucleus and I/A modes, they should attempt it during quadrant removal. Starting with a slow ramp-up time and maximum vacuum of 200 mm Hg, most will see immediately the benefits described.
Conclusion
The unique combination of transversal phaco with controlled venturi fluidics creates a highly effective and safe platform with an unmatched combination of the most important phaco elements—attractability, holdabilty, cutting ability, and followability.
