Infiniti and OZil™ Torsional Technology

Evolution to the Present

Con N. MoshegovFRANZCO FRACS

Sydney

Alcon Legacy

Alcon InfinitiAlcon Infiniti

Fluid Management SystemFluid Management System

Maximising AC maintenance and holdability of the Infiniti

FMS has two major components

1. Dual Sensing Technology1. Dual Sensing Technology

Irrigation pressure sensorIrrigation pressure sensor

Vacuum pressure sensorVacuum pressure sensor

Improved anterior chamber stabilityImproved anterior chamber stabilityExcellent holding abilityExcellent holding ability

2. Rigid Fluid Paths2. Rigid Fluid Paths

Mechanism of Occlusion BreakMechanism of Occlusion Break

Unobstructed flow

Full occlusion

Occlusion break

AquaLaseTM Technology

• Fluid pulses propelled in front of tip Fluid pulses propelled in front of tip to delaminateto delaminatetissue tissue 4 microlitres 4 microlitres ~60º C~60º CUp to 50 ppsUp to 50 pps

• No mechanical touching of tissue as No mechanical touching of tissue as in phacoin phaco

• No mechanical motion of the tip as No mechanical motion of the tip as in phacoin phaco

AquaLaseTM: indications

Perfect for clear lens extraction

Extremely good for soft cataracts:– cortical– posterior subcapsular– posterior polar– nuclear sclerotic up to 2+ (0 to 4+)

But: not good for harder nuclei

Different instruments and techniques for various nuclei

Even with Traditional Phaco SettingsEven with Traditional Phaco Settings

Depending on density of cataracts the following are modified for each situation:

• Power• Vacuum• Aspiration flow rate• Pulse and burst settings• Bottle height

Traditional Phaco SettingsTraditional Phaco Settings

The parameters are also modified depending on technique:• Divide and conquer• Pre chop• Stop and chop• Chop

Some surgeons use different settings depending on whether they’re up to 1st, 2nd or 4th quadrant

OZil™

Torsional PhacoemulsificationTorsional Phacoemulsification

Exclusive energy modality on the Exclusive energy modality on the

INFINITI™ Vision SystemINFINITI™ Vision System

OZil

For me:

One set of parameters for all densities of cataracts

Like an automatic gear box after driving a manual

Sculpt Screen – Torsional Only

100% amplitude linear for most densities

Quadrant Removal Screen: very dense nuclei

10% ultrasound power and 100% amplitude for dense lensesProbably only an occasional situation

Fixed ratio of 20 ms ultrasound then 80 ms torsional

to 10% to 100%

Torsional Ultrasound

Shearing effect

More efficient than the jackhammer effect

No repulsion since the tip is not moving toward the lens

StraightStraight

KelmanKelman

Useful only with Kelman (bent) tips

Kelman bent tip

Cutting movement at the tip is a side to side action

Small rotational displacement at wound but bigger rotational displacement at tip

Amplifies the distal tip movement

Incision

NeoSoniX™

LEGACY® 375/40

OZil™ Torsional

INFINITI™ U/S

Handpieces

Torsional PhacoemulsificationTorsional Phacoemulsification

Oscillatory motion works at a frequency lessOscillatory motion works at a frequency less

than traditional ultrasound.than traditional ultrasound.

– Longitudinal phacoLongitudinal phaco 40,000Hz40,000Hz

– Torsional phacoTorsional phaco 32,000Hz32,000Hz

– NeoSoniX NeoSoniX 100 Hz100 Hz

Longitudinal Slow Motion

Torsional Slow Motion

100% Torsional amplitude vs. 100% ultrasound power7.5 seconds with sealed incision and no irrigation or aspiration flow

OZil Studies

20% Less irrigation solution used– Less turbulence → Less egress of OVD?

OZil Personal Observations

• Transition to Kelman bent tip not as difficult as one would imagine

• Actually easier to operate on deep set eyes with it• Mechanical advantage in cracking (rotation of fingers)• Facilitates posterior extension of groove• Can angle shaft up a little if concerned (ie hold handpiece

more parallel to ground)• Can have bevel pointing to the side (laterally and medially)

OZil Personal Observations

• The feel of an OZil handpiece is no different to present Infiniti handpiece

• OZil is actually very quiet compared to US• No problem if soft (or even clear) lens• No effort involved in transition to torsional

• Ask your rep to substitute an OZil handpiece for your existing one, set machine to 100% continuous torsional and just proceed as normal

Taking OZil a step further:Microincisional Phaco

Small incision clear corneal surgery is desirable because:

Causes less induced astigmatismPossibly reduces risk of endophthalmitisQuicker stabilisation of final refraction Potentially better AC maintenance

Prospective evaluation of early visual and refractive effects with small clear corneal incision for cataract surgery.

Lyle WA, Jin GJC. J Cataract Refract Surg 1996; 22: 1456-60

Surgically induced astigmatismSurgically induced astigmatism

Microincisional PhacoMicroincisional Phaco

Two methods of microincision cataract surgery available:

Bimanual

Coaxial

Co-axial Microincisional Phaco

OZil™ Torsional Technology is possible through a 2.2mm incision using ‘Ultra Sleeve’

Any single piece AcrySof IOL can now be implanted through an unenlarged 2.2mm incision

Minor alterations to usual technique required– CCC– IOL implantation

Intrepid FMS

• Includes New Products designed specifically for the micro-coaxial procedure

• Less compliant narrow wall aspiration tubing

Available in Q1 2008

Occlusion Recovery ComparisonOcclusion Recovery Comparison

Recovery Time

mm

Hg

Occlusion Break SurgeOcclusion Break Surge

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

200 250 300 350 400 450 500 550 600

ASPIRATION VACUUM (mmHg)

Note: All testing conducted as primed with 0.9mm MicroTip and sleeve.Data on file

S

UR

GE

AR

EA

(m

mH

g*s

ec

)

Existing FMS Intrepid FMS

MONARCH® D Cartridge

Lockout Feature

30% smaller nozzle size than Monarch® C cartridge

D C

~ 33% reduction vs. ‘C’ nozzle tip

BA

D

C

Monarch III ‘D’ Cartridge & H4 (blue) Injector

Monarch II ‘C’ Cartridge & H3 (green) Injector

Very similar to the Very similar to the MonarchMonarch®® II (Green) Injector II (Green) Injector

Blue color for ease of identificationBlue color for ease of identification

Same ergonomic feelSame ergonomic feel

Same threads and lens advance rateSame threads and lens advance rate

Smaller plunger tip to accommodate the smaller Smaller plunger tip to accommodate the smaller MonarchMonarch®® D cartridge D cartridge

MONARCH® III Injector

I’ll bet…OZil™ Torsional Technology will prove to be a most popular method of phacoemulsification

Better efficiency and improved followability

Safer thermal profile

Utilized across all lens densities

Requires no change in technique

Goes well with microincisional surgery

Bimanual MICS will fall in popularity

So where does this leave AquaLase?

AquaLase – Future DevelopmentsAquaLase – Future Developments

Can’t compete with Ozil incision widths but…Can’t compete with Ozil incision widths but…– Micro Incision Tip coming: compatible with 2.2 mm Micro Incision Tip coming: compatible with 2.2 mm

incisionsincisions

May have specific applications May have specific applications – for cortex and LEC removalfor cortex and LEC removal

Looking ForwardLooking Forward

4+3+

2+1+

CortexCapsule cleaning

LEC Removal

OZilMicroCoaxial

AquaLaseMicroCoaxial

No financial interest in any of the products No financial interest in any of the products mentionedmentioned