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Innovations | May 2009

Top Products of the Year

An experienced surgeon shares his picks from 2008.

The year 2008 will be remembered for its global financial recession, but the economic downturn had little impact on the technological advances enjoyed by cataract surgeons. This article reviews innovative highlights that you may want to consider incorporating into your practice.

MICROSCOPES
Carl Zeiss Meditec (Jena, Germany), introduced Callisto Eye, the newest enhancement of the company's OPMI Lumera line of microscopes, which have featured an unparalleled red reflex. The new data management and documentation system combines operating room processes with surgical planning, and it provides surgeons with access to data on individual patients in the operating room. Callisto Eye can track consumables using a barcode scanner, and it has video documentation capabilities. In the future, the system will be like having a satellite office in the microscope.

BLADES
BD Medical-Ophthalmic Systems (Franklin Lakes, New Jersey) expanded its line of ophthalmic safety knives ranging from 1.4 to 3.2 mm. In my experience, the easy-to-use and highly effective safety shield has created a high level of peace of mind for both surgeons and surgical technicians. This is the first year that I have used a 2.2-mm safety blade to enter the anterior chamber in every one of my cases. By flaring the internal opening, I find that the incision allows improved maneuverability of the handpiece and an astigmatically neutral, watertight closure.

OPHTHALMIC VISCOSURGICAL DEVICES
Abbott Medical Optics, Inc. (Santa Ana, California), introduced the newest member of the Healon family, Healon D, a pure short-chain hyaluronic acid product with dispersive properties. The company also introduced the dual-pack systems that combine different ophthalmic viscosurgical devices. This packaging enables surgeons to take advantage of the spectrum of behavioral characteristics available within the Healon family.

PHACO TECHNOLOGY
In response to the success of microcoaxial phacoemulsification with torsional ultrasound (Intrepid Micro-Coaxial System; Alcon Laboratories, Inc., Fort Worth, Texas), the two other major US manufacturers of phaco machines introduced new technology. From Abbott Medical Optics, Inc., the WhiteStar Signature System with Fusion Fluidics offers transversal ultrasound (Ellips Transversal Ultrasound) in which the needle can move in a side-to-side rather than in a straight back-and-forth motion. The Stellaris Vision Enhancement System (Bausch & Lomb, Rochester, New York) offers a microcoaxial approach with longitudinal ultrasound through a 1.8-mm incision. Additionally, Oertli Instrumente AG (Berneck, Switzerland) introduced a 1.6-mm coaxial procedure, and Richard Packard, MD, FRCS, FRCOphth, of the United Kingdom, has developed a 0.7-mm phaco tip for microcoaxial phacoemulsification. Having published the initial series of microcoaxial phaco procedures, I have found it exciting to see the emergence of these new technologies with improved fluidics and incisions small enough to avoid induced surgical astigmatism. Today's cataract removal system must permit the refractive cataract surgeon to achieve astigmatic neutrality.

Surgeons who prefer a straight tip but would like to experience the benefits of torsional ultrasound can do so by using the new OZil 12 tip released by Alcon Laboratories, Inc., at the 2008 American Society of Cataract and Refractive Surgery annual meeting. Independently co-designed by Takayuki Akahoshi, MD, and myself, the modified bent tip with an angulation of 12° was introduced in two configurations with a Kelman-type bend or a reverse Kelman bend.

PRELOADED INJECTORS
Long overdue, preloaded injectors are now available in Europe from Hoya Vision Care Europe (Uithoorn, Netherlands), Carl Zeiss Meditec, STAAR Surgical Company (Monrovia, California), Ophthalmic Innovations International, Inc. (Ontario, California), and PhysIOL (LiŽge, Belgium). Alcon Laboratories, Inc., plans to introduce the AcrySert C in the United States soon. Finally, US surgeons will be able to avoid iatrogenic damage to the lens and the potential for contamination of the IOL.

IOLs
Cracking the 2-mm barrier in the United States, the Akreos hydrophilic acrylic IOL (Bausch & Lomb) gained US Food and Drug Administration (FDA) approval in 2008. Abbott Medical Optics, Inc., introduced its Tecnis 1-piece IOL with the new DK7786 injector designed by Duckworth & Kent Ltd. (Hertfordshire, England). Santen, Inc. (Napa, California), began clinical studies of a lens that reportedly has no glistenings.

In the field of presbyopia-correcting lenses, the AcrySof IQ Restor IOL +3.0 D (Alcon Laboratories, Inc.) completed clinical trials and recently gained FDA approval. Launched during the European Society of Cataract and Reractive Surgeons annual meeting, the lens allows surgeons to tailor their IOL selection based upon the patient's preference for reading or vision at intermediate distance. Moreover, the lens may allow a better approach to mixing presbyopia-correcting IOLs. Bausch & Lomb's Crystalens HD also received FDA approval. This accommodating IOL offers patients a significant improvement in near acuity. Early indications are that this lens is going to be popular in the United States.

The AcrySof Toric IOL (Alcon Laboratories, Inc.) rapidly continues to gain acceptance and probably represents the most explosive segment of the IOL market. No ophthalmologist would consider prescribing glasses without giving the patient the benefit of cylindrical correction, and I feel the same should be true when surgeons choose an IOL. I offer the AcrySof Toric IOL to any patient with 1.00 D or more of regular corneal astigmatism. Although I am considered the father of cataract surgery combined with astigmatic keratotomy for preexisting astigmatism, I am the first to admit that all incisional astigmatic procedures are an inexact art. Toric lenses are a precise science. Moreover, these IOLs reintroduce the wow factor, because patients see better than ever before.

Both Rayner Intraocular Lenses Ltd. (Hove, East Sussex, United Kingdom) and Carl Zeiss Meditec have released highly effective multifocal toric lenses in Europe. The Acri.LISA toric lens (Carl Zeiss Meditec) is especially interesting because it can be delivered through a 1.6-mm incision, which provides an astigmatically neutral procedure.

INSTRUMENTS
As incisions become smaller, it is more difficult to obtain microscissors and microforceps that are capable of reaching certain meridians in both the horizontal and a vertical plane. Getting oarlocked can be frustrating, especially in cases of iris reconstruction or complex IOL maneuvering. Crestpoint Management Ltd. (St. Louis; formerly Duckworth & Kent USA Ltd.) in association with Geuder AG (Heidelberg, Germany) introduced a unique set of microscissors and microforceps that I designed (I do not receive royalties for these instruments). They feature multiple angled configurations to allow access to different meridians inside the eye. For example, surgeons desiring to create a right-angle cut can select scissors that cut 90° to the incisional axis in either the horizontal or vertical plane through a 2-mm incision.

DEVICES
Soft prosthetic iris devices with color options have allowed one of my partners, Michael Snyder, MD, to help a number of children with aniridia. Maintaining a small incision while achieving a functional, cosmetic iris is now possible.

The new Malyugin ring (MicroSurgical Technology, Redmond, Washington), now enlarged to 7 mm, is helpful for managing the epidemic of intraoperative floppy iris syndrome (IFIS) secondary to the use of tamsulosin. Healon5 (Abbott Medical Optics, Inc.) and Shugarcaine1 can also be used successfully in cases of IFIS, I have found, to work beautifully when the pupil has either constricted or failed to dilate due to IFIS.

Another intriguing device is the iStent (Glaukos Corp., Laguna Hills, California), which is designed for patients with surgical cataract who also have glaucoma. This trabecular bypass microstent is reportedly easily implanted into Schlemm's canal via the same small temporal incision used for phacoemulsification.

DIAGNOSTICS
The winner in this category is the ORange intraoperative wavefront aberrometer (WaveTec Vision, Aliso Viejo, California). This technology enables real-time analysis of sphere, cylinder, axis, and higher-order aberrations based on wavefront technology. If this technology proves to be accurate, it may become routine to confirm the correct IOL power in a cataract patient who has had previous refractive surgery or to orient a toric lens with precision at the conclusion of surgery.

Iris fingerprinting is currently my preferred technique for accurately aligning a toric lens in the operating room. For the past 3 years, I have been working to develop simple but accurate technology that will eliminate the insensitive and time-consuming marking procedures that frustrate the refractive cataract surgeon. I presented several solutions when I delivered the Charles D. Kelman Innovator's Lecture at the annual ASCRS meeting in San Francisco in April.

Haag-Streit AG (Kšniz, Switzerland) introduced Lenstar LS 900, a remarkable noncontact device that takes only seconds to gather crucial ocular measurements including central corneal thickness, keratometry, pupillometry, white-to-white, lens thickness, anterior chamber depth, axial length, and the eccentricity of the optical axis.

BUGS AND DRUGS
Surgeons continue to focus on lid margin disease as a potential source of endophthalmitis. The NutriDox Convenience Kit (Advanced Vision Research, Woburn, Massachusetts) was created to facilitate the preoperative care of patients with meibomian gland disease. The kit contains doxycycline and a novel portable warm compress system (iHeat).

There seems to be increasing support for using azithromycin 1% ophthalmic solution (AzaSite; Inspire Pharmaceuticals, Inc., Durham, North Carolina) for the treatment of blepharitis.

A new fluoroquinolone, besifloxacin, is undergoing clinical trials by Bausch & Lomb.

Two peer-reviewed articles suggest the efficacy of drug delivery systems that will gain popularity in the future. Lane et al published the results of their prospective, randomized, open-label study evaluating the safety of intracameral moxifloxacin for endophthalmitis prophylaxis.2 Smith et al evaluated the antimicrobial activity of acrylic IOLs soaked in fourth-generation fluoroquinolones. Their in vitro study demonstrated that commercial-grade IOLs can act as a drug depot, producing antimicrobial activity.3

Triesence (Alcon Laboratories, Inc.) is a preservative-free formulation of triamcinolone acetonide that has proven to be a useful tool for visualizing vitreous. When Scott Burk, MD, PhD, one of my partners, published this important concept,4 we were concerned about the potential toxicity of the preserving agent, which required several time-consuming steps to remove. In contrast, Triesence can be drawn up from the bottle, diluted, and injected in a matter of moments.

Durezol (Sirion Therapeutics, Inc.,Tampa, Florida) is the first new topical ophthalmic corticosteroid introduced in the past 3 decades. In June, the company received FDA approval to market difluprednate 0.05% in a benzalkonium chloride-free emulsion. Several large studies in Japan and the United States concluded that this steroid preparation is an extremely potent antiinflammatory agent that demonstrates efficacy in even the most severe cases of uveitis.

EDUCATION
With 3D-Eye Home, Eyemaginations, Inc. (Towson, Maryland), introduced a series of educational topics that patients may review in the comfort of their own homes. Advances in the development of the surgical simulator also make this expensive technology attractive to residency programs.

The Video Journal of Cataract and Refractive Surgery will be celebrating its 25th year by launching a Web site, while the first 100 issues are being made available for viewing on Eyetube.net, a site developed by Bryn Mawr Communications LLC, the publisher of CRST Europe.

Robert H. Osher, MD is a Professor of Ophthalmology at the University of Cincinnati, Medical Director Emeritus of the Cincinnati Eye Institute, Editor of the Video Journal of Cataract and Refractive Surgery, and a member of the CRST Europe Global Advisory Board. He states that he is a consultant to multiple companies but acknowledged no financial interest in the products mentioned herein. Dr. Osher may be reached at tel: +1 513 984 5133, ext. 3679; e-mail: rhosher@cincinnatieye.com.

May 2009