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Innovations | Sep 2007

Phacoemulsification Systems

Advanced Medical Optics, Inc. (Santa Ana, California)
Advanced Medical Optics, Inc. will launch its new phacoemulsification system at the European Society of Cataract and Refractive Surgeons (ESCRS) in Stockholm, Sweden. The WhiteStar Signature System with Fusion Fluidics (Figure 1) combines the proven performance of Advanced Medical Optic's WhiteStar technology with the safety of a revolutionary Fusion dual-pump fluidics system. A streamlined user interface and easy-to-use accessories enhance efficiency of the operating room environment.

One of the most unique features of the WhiteStar Signature system is its Fusion Fluidics technology. This system provides the ultimate chamber stability and effectively reduces postocclusion surge by a significant margin. Fusion Fluidics contains advanced chamber stability safety features; its high flow and vacuum capabilities provide a peristaltic flow of up to 60 cc/min and maximum vacuum of 650 mm Hg.

Dual pumps. The dual peristaltic and venturi pump capability, to be released later this year, offers on-the-fly switching. Its responsiveness has the performance of a venturi pump and the control of a peristaltic flow-based pump to provide a stable environment for the surgeon and patient.

Another feature of the fluidics technology is what some surgeons have referred to as an antisurge algorithm, which recognizes occlusion and adjusts the maximum vacuum level downward before the occlusion break occurs. The algorithm reverses the pump to step-down the vacuum and can react in as few as 26 milliseconds. Breaking occlusions from a much lower vacuum level significantly reduces surge and augments chamber stability, according to David F. Chang, MD, of Los Altos, California. He has performed 90 procedures with the new phaco system. Additionally, company bench tests show that using a 20-gauge tip with this antisurge algorithm reduced surge by 56%.

WhiteStar technology reduces the amount of phaco energy directed into the eye and provides full ultrasound cutting efficiency. Surgeons have noted that nuclear fragments are drawn safely and efficiently to the phaco tip, in a phenomenon that has been termed magnetic followability. The result is visibly clearer corneas one day postoperatively, without changing technique.

Additional benefits. Other features of the WhiteStar Signature system include a one-step autoloading tubing pack, a faster prime cycle, a touch screen designed to be more intuitive, a wireless foot pedal, voice confirmation, and greater ease of programming. The phaco system also offers an advanced video overlay tool with real-time blending of system data and surgical video, customized viewing of procedures and data, high-definition, customizable presentation capability, and a frame-by-frame teaching tool.

For more information, visit www.amo-inc.com.

Alcon Laboratories, Inc. (Fort Worth, Texas)
The Infiniti Vision System (Figure 2) provides surgeons with the tools to create customized treatments for each eye's unique landscape. Its platform design, with custom energy solutions, increases the surgeon's effectiveness and safety to optimize treatments.

Unique treatment modules. Equipped with the proprietary OZil torsional handpiece (Figure 3), Infiniti delivers side-to-side oscillating ultrasonic movement to efficiently remove all lens densities. With virtually no repulsion, it delivers a level of followability that will dramatically alter the way surgeons perform phaco.

The Infiniti Vision System also comes with the AquaLase Liquefaction device, which when used on soft-to-medium density cataracts, enables surgeons to safely wash lenses away and optimize capsular safety simultaneously.

Microcoaxial. The emerging microcoaxial technologies are advancing surgical techniques and changing the way cataract lens removal is performed. With the company's commitment to developing this breakthrough technology, surgeons are assured that their patients will have access to the best products available today through every step of the microcoaxial cataract procedure.

Furthermore, the OZil torsional handpiece is the ideal modality for microincision techniques and is specifically designed to increase cutting efficiency and control. The system is built with an improved thermal safety profile and Intrepid Fluidic Management System—specifically designed for improved fluidics during microcoaxial phacoemulsification.

The Mini-Flared ABS and Intrepid I/A tips are designed to enhance torsional ultrasound and I/A through microincisions. These system additions facilitate occlusion and dispersion of nuclear fragments and deliver enhanced irrigation and surge suppression.

The unparalleled fluidics management system provides enhanced stability and control so that the surgeon can better focus on, and customize, individual needs. Its low-compliance (ie, rigid) design increases surgical efficacy without sacrificing efficiency. Unsurpassed surge suppression and a high-performance pump mechanism allow for smooth and precise fluidics sensing and adjustments in the changing ocular environment. Molded fluid paths and thick-wall polymer aspiration tubing decrease postocclusion surge and increase fluidic response and accuracy.

The system's unique and patented elastomer membrane allows vacuum levels up to 600 mm Hg and above to help increase the effectiveness of delivered energy and decrease peristaltic pulsations.

Custom power modulations and fluidics. Alcon Laboratories, Inc. offers a wide range of technologies in making every microcoaxial procedure as effective as possible. The Infiniti Vision System contains custom power modulations that provide the surgeon with a range of energy options for different patient needs.

For more information, visit www.infinitivision.com.

American Optisurgical, Inc. (Lake Forest, California)
American Optisurgical, Inc.'s Horizon Phacoemulsification System is a complete anterior segment surgical system (Figure 3). Lightweight, portable, and affordable, it offers high-end performance and features a small, uniquely attractive console. Additionally, it features a large liquid crystal display (LCD) touch-screen with user-friendly controls that may be preset with up to six different user programs. Other features include microphaco mode, multimodulation phaco, a programmable foot pedal, an easy loading tubing cartridge, as well as an ultra light, 40-kHz, all-titanium, four crystal ultrasound handpiece. The system can be used with a variety of small incision tips and reusable or disposable tubing.

For more information, email the company at info@optisurgical.com.

Bausch & Lomb (Rochester, New York)
Bausch & Lomb's Stellaris Vision Enhancement System (Figure 4) completes the company's microincisional cataract surgery (MICS) platform and provides a complete 1.8-mm MICS solution. Together with the company's Akreos Microincisional Lens (injectable through a 1.8-mm incision), the customized MICS instrumentation, and the MICS Education Program, the Stellaris system is the cornerstone of a comprehensive MICS platform.

The safe, efficient, and easy-to-use Stellaris system was designed in conjunction with more than 200 leading international surgeons and more than 50 operating room staff. The Stellaris system has an ergonomic and intuitive design with optimized fluidics and power. This makes the Stellaris system the ideal 1.8-mm MICS solution for use in both biaxial and coaxial MICS.

Stellaris EQ Fluidics. Stellaris EQ Fluidics provide exceptional chamber stability and safety throughout the procedure, balancing the aspiration dynamics in either vacuum or flow modes. For the vacuum mode, the EQ Vacuum Fluidics Module uses a pioneering vacuum system for excellent responsiveness and aspiration efficiency at high vacuum levels.

The StableChamber tubing system should be used in conjunction with the EQ Fluidics Vacuum Module. The StableChamber tubing system uses reduced diameter tubing to give greater holding power and lower flow rates, with reduced postocclusion surge at higher vacuum levels. An integral micromesh filter, which captures nucleus material, prevents clogging.

In the flow mode, the EQ Advanced Flow Module is a single module that allows surgeons to toggle intraoperatively between flow and vacuum modes. For instance, a surgeon may select flow for sculpting and then switch to vacuum response for segment removal, cortical clean-up, and capsule polishing. The Stellaris EQ sensing technology monitors vacuum levels in the flow mode, and precisely measures and controls the vacuum when in the vacuum mode.

Efficient delivery of power. Surgical efficiency is provided through a new six-crystal ergonomically designed handpiece, which provides efficient cutting and optimized cavitation. The handpiece has an increased stroke length for more effective transfer of energy to the nucleus with enhanced cutting. This low-frequency handpiece (28.6 kHz) delivers optimal cavitation with minimal thermal loading. Further surgical efficiency stems from the new CustomControl Software II. The customizable and programmable wavefront power modulations are suitable for all techniques (eg, biaxial or coaxial MICS).

Ergonomically designed. Easy use is paramount, so every detail of the Stellaris system has been designed to maximize its user-friendliness and minimize the learning curve. Customizable to all techniques, particularly biaxial and coaxial MICS, the system's overall ergonomic design ensures surgeon comfort. The handpiece is designed to minimize fatigue for all hand sizes. An intuitive 18-inch touch-screen display has video inlay capabilities to view the surgery and conduct training. The wireless foot pedal provides the convenience of wireless Bluetooth (Bluetooth SIG, Bellevue, Washington) connectivity. An all-electric system eliminates the need for nitrogen tanks and external gas lines.

The Stellaris system is easily upgradeable to incorporate future technical enhancements owing to its modular design. Proactive customer support is available via the Trulink Customer Support Network connectivity. This allows Bausch & Lomb to remotely monitor the equipment parameters. The data is analyzed to ensure peak performance and a field service engineer will service the system where preventative or remedial service is required.

For more information visit, www.micsplatform.com.

Dutch Ophthalmic Research Center (D.O.R.C.; Zuidland, Netherlands)
The Associate 2500 vitrectomy and phacoemulsification machine (Figure 5) is 20-, 23-, and 25-gauge compatible, and includes phaco technology for MICS. This system features a front panel with color-coded function modes and a large clear LCD display. The system has a peristaltic pump with high-vacuum occlusion technology for advanced capsular protection. A venturi pump allows for selectable vacuum rise time. Additionally, 40-kHz phaco technology provides continuous autotuning. A dual linear footswitch on D.O.R.C. products offer simultaneous linear control of both aspiration and phaco power. This dual linear control provides exquisite control during intraocular manipulation and reliable action close to the posterior capsule.

For more information, visit www.dorc.nl

D.O.R.C. (Zuidland, Netherlands)
The Harmony Total TTC (Figure 6) is a complete ophthalmic system specially designed for phaco and vitreoretinal surgery. Color-coded function modes with clear light-emitting diode (LED) indicators, in conjunction with a compact design, assures an easy-to-operate and user-friendly system. The Ergo dual-linear function footswitch provides the surgeon complete control of all major surgical functions without assistance from the surgical team. The combination of these features allows the Harmony Total TTC to offer the perfect blend of performance and ease of operation.

The Harmony Total TTC offers following essential functions for vitreoretinal surgery and phacoemulsification:
• Complete capability for all phacoemulsification and fragmentation procedures including dual linear control of aspiration;
• 40-kHz phacoemulsification (anterior) and fragmentation (posterior) procedures;
• Linear phaco mode 1- to 15-pulse/sec; and
• Continuous autotuning.

For more information, visit www.dorc.nl

Fritz Ruck Ophthalmologische Systeme GmbH (Eschweiler, Germany)
Sales for the PentaSys2 (Figure 7) started in October 2006, after the success of PentaSys1 (distributed by Carl Zeiss Meditec, France, Le Pecq, France).

The PentaSys2 system is modular so it may be used as a cataract system or extended into a full-vitrectomy system.

Capsular bag stability. The new technology in the company's pump resolutions assures stability in the capsular bag during surgery and the antisurge system balances every vacuum fluctuation in the eye.

The PentaSys2 is available with venturi pump, peristaltic pump, or as a dual pump system with switchover during surgery. There is no need to change the day-use cassette or tubing during surgery, because its versatile pump works in both anterior and posterior segment surgeries.

The peristaltic pump works in the range of 0 to 720 mm Hg and 0 to 120 mL/min linear by flow controlled by a footswitch. The range of the venturi pump is 0 mm Hg to 650 mm Hg in 0.6 seconds rising time (at the fastest setting).

Automatic infusion pressure matched to every step in surgery. With PentaSys2, users may choose infusion by gravitation or an intraocular pressure (IOP) set, which can then be saved for later use. Additionally, the surgeon may control IOP with the system's footswitch.

No difference between anterior or posterior cutter. The system's electric and pneumatic cutter (comes in either reusable or disposable) can be used in both the posterior and anterior segments. There is no need to change the cutter when moving between the two. With the integrated solutions, this system offers the possibility of 0 to 2,500 cycles per minute.

Control with dual-linear footswitch.
When developing the footswitch for the PentaSys2, we wanted to ensure that the surgeon could engage the optional joystick or bumpers whenever he/she wanted. The system allows linear control of the vacuum, flow, cutting rate, and phaco power.

With the PentaSys2, surgeons have every known phaco mode at their fingertips (eg, duration, pulse [1-35-pulse/sec], cool phaco, small incision, bimanual phaco). A variety of tips are also available (eg, straight, 45º, turbo). The combination of the system's powerful handpiece and turbo tips gives the machine one of the shortest phaco times on the market.

With its internal IOP system (range, 0 to 200 mm Hg), linear silicon oil infusion, aspiration, and internal xenon light, surgeons may perform every type of vitrectomy. Additionally, a special 4,200 Kelvin light color makes toxic reactions during the surgery impossible. Optional color filters to improve visibility are also available.

For more information, email the company at info@fritzruck-gmbh.de.

Mediphacos, Ltd. (Minas Gerais, Brazil)
The Regency 2020 provides every safety and operational feature required for the latest phaco techhniques. This is the ideal phacoemulsifier for who are looking for high-quality and safety in a cost-efficient machine. Regency 2020 is in use in more than 2,000 centers around the world.

Features of the Regency 2020 include:
• Continuous and pulse ultrasound phaco modes;
• Mechanized I/A;
• Anterior vitrectomy;
• Bipolar cautery;
• Advanced peristaltic pump;
• Anterior chamber antisurge system (ACASS);
• Aspiration reflux;
• Vacuum (500 mm Hg);
• Adjustable aspiration rate from 10 to 40 cc/min;
• Vacuum level audio feedback; and
• Digital displays.

Additionally, the machine comes with a multifunction foot pedal, reusable and disposable accessories, and an internal air compressor.

The unique ACASS technology guarantees anterior chamber stability throughout the procedure, even at high levels of vacuum and aspiration. Microprocessor controllers constantly monitor real-time vacuum levels and automatically adjust pump and fluidics controls when necessary.

Regency 2020's phaco handpiece is the lightest available. It is 100% titanium, and comes with a 1-year warranty. Its unique system of independent piezoelectric crystals provides strength and robustness to tackle nucleous of all densities, with optimum performance.

Ergonomic footswitch. An ergonomic footswitch features five functions and stage activation, indicated by a warning sound and vibration. It controls irrigation, I/A, pulse and continuous ultrasound, vitrectomy, cautery, and aspiration reflux. This footswitch provides the surgeon with full control.

Complete range of accessories. Mediphacos offers a full range of disposable and reusable accessories for the Regency 2020 including coaxial or bimanual I/A handpieces and tips; instruments for bipolar diathermy; anterior vitrectomy probes, autoclavable tubing sets; test chambers; infusion sleeves; and a wide range of phaco needles. All accessories come with Mediphacos' performance, safety, and quality warranties.

For more information, visit www.mediphacos.com

CV SERIES (6000, 7000, 24000)
Nidek Company, Ltd. (Gamagori, Japan)
Launched in Europe in 2005, the Nidek CV-7000 phacoemulsification system (Figure 8) was first used throughout Asia with great success and excellent clinical outcomes. When paired with Nidek's Nex-Acri IOL, the two products offer the cataract surgeon advanced technologies at an affordable price.

The Nidek CV-7000 phacoemulsification system delivers a new standard in cataract surgery, providing a high-repetitive pulse mode for excellent operability and reduced thermal/heat generation. The Pro-Pedal Mode achieves a high anterior chamber stability for greater visualization and fast surgery times. The CV-7000 also delivers improved peristaltic technology for a faster (up to 40%) set-up time, compared with conventional phaco systems. The system's newly designed reusable titanium handpiece delivers 40 kHz of ultrasound for phacoemulsification. Additionally, the system offers a user-friendly color touch-screen and an improved user interface for accurate treatment parameters.

The Nidek CV-7000 system delivers a complete and comprehensive phacoemulsification platform for cataract surgery.

Nidek also offers CV-24000 and CV-6000 phacoemulsification machines.

For more information visit, www.nidek.com.

Oertli Instruments AG(Berneck, Switzerland)
CataRhex SwissTech (Figure 9) is smaller, lighter, and easier to move then other systems on the market. It is the ideal system for places where space is at a premium, as well as for surgeons who wish to be mobile. It is also perfect for multisurgeon centers with medium-to-high volumes.

Console design. The CataRhex SwissTech state-of-the-art surgical console offers all of the functions necessary for anterior segment surgery. The technology has an I/A system with a noncontaminating pressure measurement, bipolar diathermy, and high-speed vitrectomy as well as phaco control using cool micropulse phaco (CMP), and 1.6-mm coaxial microincisional cataract surgery (CO-MICS). With its genuine portability, the CataRhex may be mounted on any infusion stand and is equipped with a simple tubing system, sensor, and multifunctional foot pedal. The device also offers four methods of output modulation (ie, continuous linear, pulse, burst, CMP).

The CataRhex SwissTech has a simple control surface that ensures immediate access to every function. Its fast and simple unit preparation means shorter change times between operations, and the rapid programming and call-up mode of multimode programs offer functionality during surgery.

CataRhex uses an innovative design concept, offering distinct advantages over other phaco systems including:
• The leading peristalic system; rapid, rapid, direct and perfect foot pedal control;
• DirectAccess response to button actuation without the need for a multilevel user menu;
• Portablility, (5.6 kg) and attachment versatility for any type of infusion stand;
• Bipolar capsulotomy, idea for intumescent, juvenile, and hypermature cataracts and small pupils;
• Bipolar glaucoma function sclerathalamotomy;
• Varying intensities of ultrasound for every degree of cataract hardness; and
• A 1.6-mm incision size for coaxial phaco.

Oertil Instruments AG also sells the double pump OS3 Microincision Combination System for 1.6-mm CO-MICS. (See Innovations, pg 80 for product description).

For more information, visit www.oertli-instruments.com.

Optikon Ophthalmic Equipment (Rome)
Reliable, compact, safe, and versatile, the Pulsar2 Minimal Stress unit will meet any surgeon's desires and any institution's needs. Its patented and unique phaco driver minimizes the ultrasonic energy delivered to the eye.

The unit includes a wide range of MICS accessories such as phaco needles for 1- to 1.5-mm incisions, an irrigating chopper, nucleus manipulator, capsulorhexis forceps and bimanual I/A probes.

Additionally, it boasts the first disposable ultrasound handpiece with built-in tip and sleeve. A wide range of 23-gauge accessories for minimally invasive vitrectomy include a high-speed posterior vitreous cutter, round incision knife, infusion scleral cannula, microforceps, aspiration cannula, and endo-illuminating fiber optic probe. The new xenon light source is based on 5,100º Kelvin high-efficiency high-intensity discharge lamp for maximum light intensity and extended life-span (50 times longer than standard halogen lamp).

Pulsar2 is also equipped with a venturi/peristaltic pump system to fit any surgical technique and preference. With this system, the user can switch in full flight between the two pumps during the different phases of the surgical procedure, without changing the I/A tubing set (reusable and disposable versions are available).

User-friendly software with functions and control icons visible is easy to use, and an intuitive graphic layout and highlighted and easily visible preset values add to the value of this machine.

For more information, visit www.optikon.com.

(At press time, the editors were unable to obtain information from a Optikon representative. Product descriptions were gathered directly from the company Web site.)

STAAR Surgical Company (Monrovia, California)
During sonic phaco with the Sonic Wave (Figure 10), there is continuous tip movement (range, 20-400 Hz), which can be compared with standard ultrasound mode (tip movement, 40 kHz). This reduction in frequency directly correlates to a reduction in heat and energy transferred into the eye and makes the procedure safer for the patient. The Sonic Wave system also has the ability to switch from sonic to ultrasound via the foot pedal and allows for removal of hard cataracts (eg, grade 4).

The Sonic Wave boasts 50-times less frictional heat and creates no cavitation, eradiated heat energy (shock waves), or microbubbles. The benefits include better control for softer material and the elimination of thermal injury.

Load compensating and autotuning handpiece. As handpiece crystals age, its optimal operating frequency drifts. Most phaco machines tune the handpiece prior to surgery to compensate for these drifts. If the handpiece needs to be replaced during surgery, the new handpiece must then be tuned. The Sonic Wave, however, tunes 1,000 times/sec, removing the need to retune the handpiece when it is unplugged and ensuring it is always operating at maximum efficiency.

In addition to autotuning capabilities, the handpiece is also load sensing. Where most phaco machines advertise a stroke length of 0.004 inch at 100% phaco, actual displacement and cutting ability under load may vary. The Sonic Wave, however, delivers more power to the crystals when under load conditions allowing for successful cataract removal at low ultrasonic power.

Perivent fluidics. Using the safety and controllability of peristaltic systems and the speed (ie, rise time) of venturi systems, Perivent is a unique hybrid in fluidic systems. In standard peristaltic systems, the pump motor must stop when the vacuum limit is reached, whereas in the Perivent system, the pump continues to rotate even after reaching maximum vacuum level. The vacuum level is maintained by venting into the atmosphere. The major benefit to this system is its improved postocclusion flow. When the occlusion breaks, instantaneous flow volume is available due to the elimination of motor spool-up time.

In autocorrelation mode, the footswitch can increase or decrease ultrasonic power, vacuum and flow simultaneously. Suppose, for example, that the autocorrelation is set for flow in the third position and vacuum is set in the second position. (The vacuum limits are 100 and ±300 mm Hg. The flow limits are 28 and 32 cc/min). When an occlusion occurs in foot position two, vacuum can be increased as the footswitch travels from the bottom to the top of position two from 300 to 500 mm Hg. Meanwhile, the flow remains constant at 35 cc/min. If the occlusion does not clear in position two, the footswitch enters position three, and ultrasound is activated. The vacuum remains at 300 mm Hg, but now the flow decreases in anticipation of an occlusion breakage. This feature further reduces the risk of postocclusion chamber collapse.

For more information, visit www.staar.com.