Microcoaxial surgery


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Perfect Vision's Dr Con Moshegov presentation on: Microcoaxial surgery

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Microcoaxial surgery

  1. 1. The Art of Micro-coaxial Lens Replacement Con N. Moshegov Sydney
  2. 2. Microincisional Phaco <ul><li>Small incision clear corneal surgery is desirable because: </li></ul><ul><li>Causes less induced astigmatism </li></ul><ul><li>Possibly reduces risk of endophthalmitis </li></ul><ul><li>Quicker stabisation of final refraction </li></ul><ul><li>Potentially better AC maintenance </li></ul><ul><li>Prospective evaluation of early visual and refractive effects with small clear corneal incision for cataract surgery. </li></ul><ul><li>Lyle WA, Jin GJC. </li></ul><ul><li>J Cataract Refract Surg 1996; 22: 1456-60 </li></ul>
  3. 3. Surgically induced astigmatism
  4. 4. Microincisional Phaco <ul><li>Two methods of microincision cataract surgery available: </li></ul><ul><li>Bimanual </li></ul><ul><li>Coaxial </li></ul>
  5. 5. <ul><li>3 groups each of 5 human cadaver eyes </li></ul><ul><li>Underwent simulated phaco by </li></ul><ul><ul><li>Standard phaco (2.75mm) </li></ul></ul><ul><ul><li>Bimanual phaco (2 x 1.2mm) </li></ul></ul><ul><ul><li>Microcoaxial phaco (2.2mm) </li></ul></ul><ul><li>Wound integrity assessed by noting aqueous leakage and India ink penetration </li></ul><ul><li>Wound architecture examined with SEM </li></ul>
  6. 6. Microincisional Phaco <ul><li>Spontaneous wound leakage evident in all 5 of the bimanual group, 1 of the standard group and none of the 2.2mm coaxial group </li></ul><ul><li>Whitening and edema of wound edge present in 4 eyes of the bimanual group and in none of the others </li></ul><ul><li>India ink penetrated the 1.2mm wounds of the bimanual group but not the coaxial group </li></ul><ul><li> (India Ink particles have roughly the same size as bacteria) </li></ul><ul><li>Greater endothelial cell loss and compromise to Descemet’s membrane near wound in bimanual group </li></ul>
  7. 7. Microincisional Phaco <ul><li>Why so? </li></ul><ul><li>Stress from instrument manipulation within an overly tight wound </li></ul><ul><li>Increased heat from a sleeveless tip </li></ul>
  8. 8. Microincisional Phaco <ul><li>Other disadvantages of bimanual MICS: </li></ul><ul><li>CCC with conventional forceps not possible </li></ul><ul><li>Necessitates chopping technique </li></ul><ul><li>Necessitates irrigating chopper: </li></ul><ul><ul><li>Restricted inflow -> difficulty maintaining AC </li></ul></ul>
  9. 10. Microincisional Phaco <ul><li>OZil™ Torsional Technology is possible through a 2.2mm incision using ‘Ultra Sleeve’ </li></ul><ul><li>Any single piece AcrySof IOL can now be implanted through an unenlarged 2.2mm incision </li></ul><ul><li>Minor alterations to usual technique required </li></ul><ul><ul><li>CCC </li></ul></ul><ul><ul><li>Micro tip and Ultra sleeve </li></ul></ul><ul><ul><li>I/A </li></ul></ul><ul><ul><li>IOL implantation </li></ul></ul>
  10. 11. Microincisional Phaco <ul><li>Some capsulorhexis forceps cannot be opened inside the 2.4mm (or smaller) incision </li></ul>
  11. 12. <ul><li>No good: </li></ul><ul><li>Masket forceps from Katena (K5-5084 & K5-5084a) </li></ul><ul><li>Kraff-Utrata forceps from Asico (AE-4394 & AE-4394a) </li></ul><ul><li>Good: </li></ul><ul><li>Utrata from Katena (K5-5081 & K5-5081a) </li></ul><ul><li>Inamura cross action from Duckworth & Kent (2-716-2R) </li></ul><ul><li>Vitreo-retinal micro-forceps not necessary </li></ul>
  12. 13. 0.9 mm MicroTip 0.9 mm Flared Tip 0.9 mm Tapered Tip
  13. 14. Optimal Tip for Micro-coaxial: 0.9 mm Mini-Flared Kelman ® ABS ® Tips <ul><li>Angled design enhances OZil torsional movement and efficiency </li></ul><ul><li>Flared head increases holding force and emulsification capacity </li></ul><ul><li>Narrower proximal portion permits utilization of higher vacuum and offers better surge suppression </li></ul>30 ° and 45 ° angulations
  14. 15. Irrigation/aspiration <ul><li>Smaller bore I/A tip </li></ul><ul><li>Silicone tip an option </li></ul><ul><li>Metallic tips also available </li></ul><ul><li>No change in technique </li></ul>
  15. 16. IOL implantation <ul><li>Not possible with ‘B’ cartridge </li></ul><ul><li>Modification of technique necessary with ‘C’ cartridge </li></ul><ul><li>Single handed injectors with second hand being used to provide countertraction </li></ul>
  16. 18. MONARCH ® D Cartridge 33% smaller nozzle size than Monarch ® C cartridge Lockout Feature D C
  17. 19. ~ 33% reduction vs. ‘C’ nozzle tip B A D C Monarch III ‘D’ Cartridge & H4 (blue) Injector Monarch II ‘C’ Cartridge & H3 (green) Injector
  18. 20. MONARCH ® III Injector <ul><li>Very similar to the Monarch ® II (Green) Injector </li></ul><ul><ul><ul><li>Blue color for ease of identification </li></ul></ul></ul><ul><ul><ul><li>Same ergonomic feel </li></ul></ul></ul><ul><ul><ul><li>Same threads and lens advance rate </li></ul></ul></ul><ul><ul><ul><li>Smaller plunger tip to accommodate the smaller Monarch ® D cartridge </li></ul></ul></ul>
  19. 21. NEW Monarch ® III IOL Delivery System* (INTREPID ™ Micro-coaxial System) <ul><li>Easier IOL loading vs. Monarch ‘C’ </li></ul><ul><li>2.4mm ‘through-the-wound’ </li></ul><ul><ul><li>Surgeon technique similar to Monarch II with ‘C’ with larger incision </li></ul></ul><ul><li>2.2mm wound assisted </li></ul><ul><ul><li>LESS stress vs. other systems </li></ul></ul><ul><li>AcrySof IQ (SN60WF) IOL = up to 27.0D </li></ul>*Commercial availability January 2008
  20. 23. Attributes of AcrySof IOL <ul><ul><li>Tough </li></ul></ul><ul><ul><li>No haptic damage </li></ul></ul><ul><ul><li>Slow controlled unfolding </li></ul></ul><ul><ul><li>Easy to orientate </li></ul></ul>
  21. 24. Attributes of AcrySof IOL <ul><ul><li>No tilting </li></ul></ul><ul><ul><li>Rotational stability </li></ul></ul><ul><ul><li>Blue filter </li></ul></ul><ul><ul><li>Well documented proof of low PCO </li></ul></ul>
  22. 25. Attributes of AcrySof IOL <ul><ul><li>Same platform with all variations </li></ul></ul>
  23. 26. Toric IOL needs to be rotationally stable
  24. 27. <ul><ul><li>As the pupil changes size, its centroid may not remain stationary relative to the limbus </li></ul></ul>
  25. 28. Centration relative to the pupil <ul><ul><li>With Acrysof single piece IOLs the surgeon can make an adjustment to the final position of the IOL </li></ul></ul><ul><ul><li>Where the surgeon puts it is where it will stay! </li></ul></ul>
  26. 29. <ul><li>Almost 30 million AcrySof IOL have been implanted over the last 10 years </li></ul><ul><li>One in every two foldable IOLs implanted in the World is made of AcrySof material </li></ul><ul><li>70% of these are single piece </li></ul><ul><li>Majority of these are with a blue filter </li></ul>
  27. 30. Filtering Blue Light <ul><li>The AcrySof Natural lens has not been demonstrated to have any significant negative impact on colour perception, contrast sensitivity or scotopic vision </li></ul><ul><li>Despite theoretical concerns it has not been documented to cause a significant disruption to the circadian rhythm </li></ul><ul><li>No proof that filtering blue light reduces the risk of developing ARMD </li></ul>
  28. 31. Retinal Protection: FACTS <ul><li>Mice exposed to blue light for 25 minutes have photoreceptor damage </li></ul><ul><li>If an AcrySof Natural lens is interposed between them and the light source… </li></ul><ul><li>much less damage occurs </li></ul>
  29. 32. Retinal Protection: FACTS <ul><li>Surgeons have a marked supression of blue sensitivity after performing Argon laser PRP using blue – green light </li></ul><ul><li>Lasts for several hours </li></ul><ul><li>In more senior ophthalmologists this was irreversible </li></ul><ul><li>Gunduz, K and Arden, GB. Changes in colour contrast sensitivity associated with operating argon lasers. </li></ul><ul><li>Br. J. Ophthalmol 1989 (73), 241-6. </li></ul>
  30. 33. <ul><li>‘ Every major IOL manufacturer is </li></ul><ul><li>working on the idea of a blue light </li></ul><ul><li>filtering lens’ </li></ul>
  31. 34. I’ll bet… <ul><li>OZil™ Torsional Technology will prove to be a most popular method of phacoemulsification </li></ul><ul><ul><ul><li>Better efficiency and improved followability </li></ul></ul></ul><ul><ul><ul><li>Safer thermal profile </li></ul></ul></ul><ul><ul><ul><li>Utilized across all lens densities </li></ul></ul></ul><ul><ul><ul><li>Requires no change in technique </li></ul></ul></ul><ul><ul><ul><li>Goes well with microincisional surgery </li></ul></ul></ul><ul><li>Bimanual MICS will fall in popularity </li></ul><ul><li>AcrySof will maintain it’s popularity </li></ul>
  32. 35. <ul><li>No financial interest in any of the products mentioned and no gain in endorsing them </li></ul>