Microcoaxial phaco using 1 8 mm incisions comparison

Microcoaxial phaco using 1. 8 mm incisions: comparison of two machines and IOL systems Richard Packard Windsor England Consultant for Alcon, AMO and Bausch and Lomb

Reasons for making incisions smaller • Less leakage and therefore better controlled surgery • Minimal if any induced astigmatism • Faster rehabilitation visually for the patient • Safer more rapidly healing wounds • Because we can!

3. 2 mm 2. 5 mm 2. 2 mm 1. 8 mm

Microincisions with coaxial give: • Protected wounds due to sleeve • Less changes in technique and equipment than B-MICS • Ability to use established IOL technology • Minimal astigmatism

What do we need for C-MICS • • Wounds and therefore knives that match instrumentation Microsurgical capsulorhexis forceps New sleeves that are thin and allow enough fluid passage Thinner phaco tips? Understanding hydrodissection with microincisions No change in cataract removal techniques Phaco machines with appropriate power modulation and excellent fluidics • IOLs capable of being injected with wound assistance through unopened Co-MICS incisions

Incisions for 1. 8 mm C-MICS

Capsulorhexis and hydrosteps and tip insertion for 1. 8 mm C-MICS

Stellaris System Overview • EQ Fluidics equalises fluidic dynamics for solid chamber stability in vacuum or flow modes • Ergonomic six crystal handpiece and tubing for efficient cutting and smooth removal of the nucleus in all techniques • Custom. Control™ Software II for customisable power modulation for all cataract grades • Wireless Dual Linear foot pedal for instantaneous surgeon control of aspiration and ultrasound • Sleek and ergonomically designed for operating room efficiency • Modular design customisable to both EQ Fluidics options, the Advanced Flow Module or Vacuum Fluidics Module, plus all future upgrades

Stellaris EQ Fluidics Management Technology EQualising aspiration and irrigation for unsurpassed safety, efficiency and predictability in either flow or vacuum modes for solid chamber stability throughout the procedure EQ EQ Advanced Flow Module (AFM) Vacuum Fluidics Module (VFM) Single module allows surgeons to toggle intra-operatively between flow and vacuum modes; flow for sculpting, vacuum for capsule polishing and I/A Latest generation vacuum fluidics with Stable. Chamber tubing delivers exceptional accuracy and efficiency for MICS

INFINITITM Vision System • Tri-modal – Aqua. Lase. TM – Ozil TM – Improved Traditional Ultrasound • Fluidics • User Interface • Ergonomics

Fluidic Management System • • Pump roller interface Vent valve interface Irrigation pinch valve Infusion pressure membrane • Vacuum Pressure Sensor • Intrepid. TM low compression tubing

MICS tip and sleeve for 1. 8 mm surgery with B and L Stellaris • • Straight MICS tip 30 degree bevel 0. 9 mm at widest 0. 5 mm internal diameter

Mini-flared tip and Nano sleeve for 1. 8 mm surgery with Alcon Infiniti • Curved 45 degree mini-flared tip • 0. 9 mm at widest • 0. 57 mm internal diameter

Stellaris Handpiece efficient cutting • Increased stroke length for efficient cutting of the nucleus • Tighter, more focused and consistent delivery of stroke • Custom. Control™ II Software for customisable, programmable wavefront power modulations for all techniques

Ozil. TM technology Torsional (side) stroke at tip end (action) -oscillations occur at tip/hub/horn junction -distal end of Kelman tip exhibits a “side to side” displacement due to tip geometry More Efficient Cutting with 32 KHz Torsional induces (“shearing” stress ) vs. Longitudinal u/s (“compression stress”) Longitudinal cuts on the “forward” stroke Torsional cuts both “right or left” = efficiency Translates = about 1/3 of thermal dissipation

Now that we have removed the nucleus which IOL can we use?

Akreos Microincision Lens Optimised for MICS Akreos Microincision Lens: Akreos MI 60 • Implantable through a 1. 8 mm incision using a wound-assisted injection • Biocompatible hydrophilic material with a proven record of safety, used in 2 million implantations since its introduction in 1998 • The innovative haptic design ensures excellent 3 -Dimensional stability of the IOL

Acry. Sof IQ* Aspheric Natural IOL (Alcon model SN 60 WF) • Thinner aspheric optic design for 1. 8 mm insertion with wound assistance and D-cartridge • Blue Light-Filtration • Acry. Sof Single-Piece Platform • Low PCO *IQ (Image Quality) • Material with 17 years track record

So how do they really compare? • Both deliver 1. 8 mm surgery with early visual rehabilitation due to no induced astigmatism • Both require specific knives, capsulorhexis forceps, phaco tips and sleeves • Wound assisted insertion is mandatory • Time will tell how the IOLs perform in the long term as far as PCO is concerned

Thank you