As the global population continues to age, ophthalmologists will see an influx of patients presenting not only for cataract surgery but for glaucoma surgery as well. Both procedures are effective alone, but, as the literature suggests, combining them can provide a decrease in intraocular pressure (IOP) with a low complication rate.1 Furthermore, performing either procedure in as minimally invasive a manner as possible—that is, microincision cataract surgery (MICS) and microinvasive glaucoma surgery (MIGS)— has countless advantages for the patient.
One machine that facilitates performing MICS and MIGS as standalone and combination procedures is the CataRhex 3 (Oertli Instrumente; Figure 1). Just like the first- and second-generation CataRhex machines, the main priority of the third-generation CataRhex 3 is portability. Small and light enough to be hooked to an IV pole during surgery, the CataRhex 3 is one of the most portable phaco machines on the market.
The second priority is to provide surgeons with a complete range of the functions expected from a cutting-edge cataract and glaucoma surgery device. Cataract surgery functions of the CataRhex 3 include irrigation/aspiration; contin continuous irrigation; CortexMode to enhance cortex removal and capsular cleaning; easyPhaco; multimode, occlusion mode, and CMP cool phacoemulsification; and femtosecond lens aspiration. Other surgery functions include vitrectomy, bipolar diathermy, and high-frequency deep sclerotomy (HFDS) ab interno glaucoma surgery for MIGS (Figure 2).
I have been using the CataRhex 3 since its launch at the 2013 European Society of Cataract and Refractive Surgeons (ESCRS) meeting in Amsterdam, Netherlands, and it is now my primary phaco device for cataract surgery (eyetube.net/?v=orohu). The machine may look familiar to its predecessors from the outside, but technical advances have allowed me to enhance my phaco technique and increase surgical safety.
The first advantage I have noticed with the CataRhex 3 is a more stable anterior chamber, which has allowed me to decrease my ultrasound time. In the majority of procedures, ultrasound time is less than 5 seconds. The second advantage is that I can safely use high vacuum (up to 500 mm Hg) to more effectively and rapidly emulsify the nucleus. The CataRhex 3 has four performance modulation settings for phacoemulsification: continuous linear, pulse, burst, and panel.
Another advantage is the advanced I/A system of the CataRhex 3. Irrigation flow is precisely controlled in 0.1-mL steps, and CortexMode provides rapid build-up of vacuum. When the device is set to this mode, I can emulsify the nuclear pieces quickly. A routine cataract surgery procedure now takes about 3 to 4 minutes; with a hard cataract, it may take 6 to 7. An integrated vacuum sensor monitors this step of the procedure. This, in my opinion, is one of the main advantages of the CataRhex 3 compared with the first- and second-generation devices. Additionally, the stability of fluidics with the CataRhex 3 makes bottle height adjustments unnecessary.
Performing microinvasive HFDS ab interno glaucoma surgery at the time of cataract surgery adds only 3 to 5 minutes to the procedure, but the benefits are plentiful. Direct aqueous drainage from the anterior chamber to Schlemm canal and the sclera can be created, bypassing the flow resistance of the trabecular meshwork.
During HDFS, two 1.2-mm paracenteses are created 120º apart to relieve IOP and allow access for the high-frequency diathermy instrument. This is done after phacoemulsification and IOL implantation. The anterior chamber is first refilled with additional ophthalmic viscosurgical device to make the pupil miotic, followed by placement of the diathermy probe through the paracentesis. Using the probe, with the help of a four-mirror gonioscopic lens (Figure 3A), six deep sclerotomy pockets are formed nasally or inferiorly through the trabecular meshwork and Schlemm canal (Figure 3B).
I prefer to use this combination procedure in patients with primary open-angle glaucoma who have been on antiglaucomatous eye drops for several years prior to cataract surgery. Clinically, the potential of overall decrease in IOP after combined cataract surgery and HDFS is similar to that after trabeculectomy or nonpenetrating procedures and can persist for years.
A certain learning curve is needed for MIGS procedures such as HDFS, however. The most challenging part of HDFS for many cataract surgeons is learning to visualize the trabecular meshwork temporally through the mirror to guide the applications.
The CataRhex 3 is like a sports car—it is small, but powerful. It allows me to perform cataract surgery as a standalone procedure or combined with glaucoma and retinal surgery quickly and safely. As is the case when you push the gas pedal of a sports car, you get an immediate response when you push the footpedal of the CataRhex 3. Because of its portability, power, and easy-to-use profile, I expect that the CataRhex 3 will be my preferred device for years to come.
Bojan Pajic, MD, PhD, FEBO, is a Consultant in the Division of Ophthalmology, Department of Clinical Neurosciences, University Hospitals of Geneva, Switzerland; the Medical Director of the Swiss Eye Research Foundation, Eye Clinic Orasis, Reinach, Switzerland; member of the medical faculty, Military Medical Acedemy, University of Defans Belgrade, Serbia; and a surgeon and member of the Board of Specialized Hospital Vidar-Orasis Swiss at the Eye Hospital Vidar-Orasis Swiss, University of Novi Sad, Faculty of Physics, Novi Sad, Serbia. Dr. Pajic states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: firstname.lastname@example.org.
- Augustinus CJ, Zeyen T. The effect of phacoemulsification and combined phaco/glaucoma procedures on the intraocular pressure in open-angle glaucoma. A review of the literature. Bull Soc Belge Ophthalmol. 2012;320:51-66.