Microincision cataract surgery (MICS) represents a significant change in the way that cataract surgeons perform phacoemulsification. The use of smaller incisions for phaco and IOL implantation causes less trauma to the eye during the procedure and provides better healing after surgery. The smaller incisions also have been shown to reduce surgically induced astigmatism, a side effect that can greatly affect patient satisfaction postoperatively. During the Belgian Society of Cataract and Refractive Surgery (BSCRS) meeting in January 2008, I presented two cases of MICS. In one case, I performed a coaxial microincision (C-MICS) technique. In the other, I used what I call a triaxial MICS technique. In this article, I will outline the two cases.
CASE NO. 1: C-MICS
C-MICS is my current preferred surgical technique, as I believe that the sleeve protects the wound during surgery. I used the Stellaris (Bausch & Lomb, Rochester, New York) phaco machine with a sleeved phaco tip and created a 1.8-mm incision. The Stellaris platform has an advanced fluidics control system that is independent of an external source of pressurized air because it has its own internal compressor.
A nice feature on the Stellaris is its wireless dual-linear foot control. Dual-linear control allows me to drive the surgery efficiently and quickly. I created one 1.2-mm sideport incision for the chopper and one 1.8-mm main limbal incision for microcoaxial phaco.
The anterior chamber was filled with EyeFill SC (Croma-Pharma, Korneuburg, Austria) ophthalmic viscosurgical device (OVD), which is a 2% biofermentative hyaluronic acid with a molecular weight of 3 million daltons. Continuous curvilinear capsulorrhexis (CCC) was performed using microincision forceps (Figure 1). I performed phaco chop with linear vacuum set to 350 mm Hg with ease. The instruments that I used are shown in Figure 2.
Phaco was followed by implantation of an Akreos MI60 IOL (Bausch & Lomb). I used only Ringer solution—no OVD—in the cartridge, which was placed into an Akreos PS-27 single-use injector (Bausch & Lomb). The Akreos MI60 (Figure 3) is an IOL designed for microincision, so it was easy to implant it through the 1.8-mm incision.
CASE NO. 2: TRIAXIAL MICS
Whenever I want to perform a fast surgery and be sure the anterior chamber is stable, I use what I call triaxial MICS. For this technique, I use a Pharo phaco machine (A.R.C. Laser GmbH, Nuremberg, Germany), which has a Venturi pump system and intraocular pressure control. After filling the anterior chamber with EyeFill SC OVD, I then performed CCC using microforceps. I made one 1.8-mm incision for coaxial phaco and, on top of that incision, I made one 1.2-mm incision for the irrigating chopper.
In my triaxial approach, I combine the microcoaxial sleeve with the irrigating chopper (Figure 4). To further enhance anterior chamber stability, I use the Smile sleeve (A.R.C. Laser GmbH) to seal the external wound around the irrigating chopper (Figure 5). I like using this triaxial approach because it provides enough volume of irrigating solution in the anterior chamber to compensate for high vacuum (up to 450 mm Hg). Additionally, phacoemulsification can be performed quicklywith a stabile anterior chamber.
The Pharo system was used on three cases during the BSCRS live surgery event. Wolfram Wehner, MD, of Germany, performed the first two cases. His first case was a laser cataract surgery performed with the Dodick Laserlysis System (A.R.C. Laser GmbH). His second case with the system was biaxial MICS; the third case was my triaxial technique. It is not too often that one sees a single platform used in different ways during one live surgery event.
In my case, an the Oculentis Lentis Select LS-505 IOL (Oculentis GmbH, Berlin; Figure 6) was implanted through an unenlarged 1.8-mm incision. Oculentis is the new kid on the block—a novel IOL company which was spun off from the IOL division of WaveLight (Erlangen, Germany) before its takeover by Alcon Laboratories, Inc. (Fort Worth, Texas). Oculentis Lentis is a plate haptic, hydrophilic acrylic IOL with a hydrophobic effective surface and blue-light filtering technology. The true square-edge design is a result of application of a 100% polishing-free submicron lathing technology. To the best of my knowledge, this was the first implantation of a blue-light blocking IOL through a 1.8-mm incision worldwide. The variety of IOLs for MICS is increasing as MICS gains popularity in Europe.
These two cases demonstrate how new technology, coupled with exciting techniques that utilize a variety of resources available to cataract surgeons, can result in innovative surgical advances. The Stellaris and Pharo systems offer cataract surgeons the ability to use small incisions with improved fluidics and anterior chamber stability. The modified technique that I presented with the Pharo exemplifies how a novel approach can further enhance stability and superior outcomes. Future IOL developments will continue to drive innovation in MICS.
Pavel Stodulka, MD, PhD, practices at the Gemini Eye Clinic and Bata Regional Hospital in Zlin, Czech Republic. Dr. Stodulka states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +420†577†552†986; fax: +420†577†552†986; e-mail: stodulka@lasik.cz.
