THE OUTCOMES OF MICS WITH THE OUTCOMES OF MICS WITH CRUISE CONTROL SYSTEM VS CRUISE CONTROL SYSTEM VS

MICS WITH WHITESTAR ICE AND MICS WITH WHITESTAR ICE AND CASE SETTINGS IN HARD CASE SETTINGS IN HARD

CATARACTSCATARACTS

HELVACIOGLU FiratHELVACIOGLU Firat, MD,, MD, SENCAN Sadik, MD, SENCAN Sadik, MD, OGUZHAN Hasan, MD, YETER Celal, MDOGUZHAN Hasan, MD, YETER Celal, MD

Bakirkoy Bakirkoy EducatEducatiion And Research Hospon And Research Hospiitaltal Department Of Department Of Ophthalmology, Istanbul TURKEYOphthalmology, Istanbul TURKEY

The authors have no financial interest in the subect matter of this posterThe authors have no financial interest in the subect matter of this poster

PURPOSEPURPOSE To compare the safety and efficacy of Whitestar To compare the safety and efficacy of Whitestar ICE and CASE settings with cruise control ICE and CASE settings with cruise control system in bimanual MICS.system in bimanual MICS.

Micro forceps Duet systemDivide & Conquer

METHODSMETHODS Between Between JanuaryJanuary 200 20066 and March 200 and March 20088, MICS , MICS (G1)(G1) was was performed in performed in 220 eyes of 0 eyes of 118 patients by using the AMO-8 patients by using the AMO-Sovereign Whitestar surgical systemSovereign Whitestar surgical system with the aid of cruise with the aid of cruise control system control system .. MICS MICS (G2)(G2) was performed in 20 eyes of 1 was performed in 20 eyes of 177 patients patients by by using the AMO-Sovereign Whitestar surgical systemusing the AMO-Sovereign Whitestar surgical system with with ICE and CASE settings.ICE and CASE settings.Patients were chosen according to their nuclei hardness Patients were chosen according to their nuclei hardness (grade3-4).(grade3-4). Patients were examined for:Patients were examined for:

intraoperative complications,intraoperative complications, Mean phaco timeMean phaco time Total phaco % Total phaco % EPTEPT % endothelial cell loss% endothelial cell loss postoperative corneal edema and postoperative corneal edema and anterior chamber reactions. anterior chamber reactions.

METHODSMETHODS PhacoPhaco 1 – 1 – Grooving Grooving AspirAspiration ation VaVaccccuum m WhiteStarWhiteStarUnoccludedUnoccluded & & 22 22 cc/ cc/minmin.. 50 50 mmHg mmHg 3 300%-50%%-50%Occluded Occluded LinearLinear PanelPanel LinearLinear

Phaco Phaco 2 – 2 – Chopping Chopping AspiraAspiratitioon n VaVaccccuum m WhiteStarWhiteStarUnoccludedUnoccluded & & 28 28 cc/ cc/minmin.. 335050 mmHg mmHg 30%-50% 30%-50%Occluded LinearOccluded Linear LinearLinear LinearLinear

C/F (33%) Operation cycle used in both groupsC/F (33%) Operation cycle used in both groupsICE 1 ms/constant kickICE 1 ms/constant kickCASE vaccum 200 mmHGCASE vaccum 200 mmHG

ENERGY PARAMETERS AND ENERGY PARAMETERS AND EENDOTHELNDOTHELIIAL CELL LOSSAL CELL LOSSESES

MICS + CRUISE CONTROLMICS + CRUISE CONTROLMean EPT (seconds):Mean EPT (seconds):

3.75 (SD 1.18)3.75 (SD 1.18)

Mean US time (min.):Mean US time (min.): 1.45 (SD 0.18)1.45 (SD 0.18)

Mean total phaco %:Mean total phaco %: 5.1 (SD 1.3)5.1 (SD 1.3)

MICS + ICE&CASEMICS + ICE&CASEMean EPT (seconds):Mean EPT (seconds):

3.22 (SD 1.38)3.22 (SD 1.38)

Mean US time (min.):Mean US time (min.): 1.24 (SD 0.22)1.24 (SD 0.22)

Mean total phaco %:Mean total phaco %: 4.8 (SD 1.1)4.8 (SD 1.1)

Group 2 mean end. Group 2 mean end.

preoppreop postoppostop Loss %Loss %

23762376 22532253 5.2 %5.2 %

Group 1 mean end. Group 1 mean end.

preoppreop postoppostop Loss %Loss %

23222322 21842184 5.7 %5.7 %

There was not any complication affecting the visual There was not any complication affecting the visual outcome in both groups. outcome in both groups. There was not any statistical significance between the There was not any statistical significance between the groups in the values of thegroups in the values of the;; endothelial cell lossendothelial cell loss the EPTthe EPT the rate of intraoperative complications, the rate of intraoperative complications, the grade of postoperative corneal edemathe grade of postoperative corneal edema and and

anterior chamber reactionsanterior chamber reactionsNo corneal burn was seen and both types of operations No corneal burn was seen and both types of operations were performed safely and efficiently in hard cataracts.were performed safely and efficiently in hard cataracts.

RESULTSRESULTS

POSTOPERATPOSTOPERATIIVE CORNEAL EDEMAVE CORNEAL EDEMA AND AND ANTERANTERIIOR CHAMBEROR CHAMBER REACTREACTIIONSONS

0%

10%

20%

30%

40%

50%

60%

70%

80%

G 1 gr. 3

G 1 gr. 4

G 2 gr. 3

G 2 gr. 4

None

Mild

0

2

4

6

8

10

12

G 1 gr. 3

G 1 gr. 4

G 2 gr. 3

G 2 gr. 4

None

Mild

Moderate

Severe

Postoperative Corneal Edema Postoperative Anterior Chamber ReactionsPostoperative Corneal Edema Postoperative Anterior Chamber Reactions

DISCUSSIONDISCUSSIONMICS has many advantages;MICS has many advantages;

Switch incisions, create space and manipulate lens fragments with irrigation, Switch incisions, create space and manipulate lens fragments with irrigation, Irrigate without pushing the lens fragments away from the aspiration tip, Irrigate without pushing the lens fragments away from the aspiration tip, Increase safety, less turbulent and more stable anterior chamber, Increase safety, less turbulent and more stable anterior chamber, Improved control on hydrodissection and capsulorhexsis, Improved control on hydrodissection and capsulorhexsis, less risk of leakage, theoretically reduced risk of endophthalmitis, less risk of leakage, theoretically reduced risk of endophthalmitis, accelerate visual rehabilitation, astigmatically neutral ( <1.5 mm)accelerate visual rehabilitation, astigmatically neutral ( <1.5 mm)

Main limiting factors (1);Main limiting factors (1); The limits in IOL technology (this field continues to grow rapidly),The limits in IOL technology (this field continues to grow rapidly), the narrow lumens of the irrigating choppers that limits the max vacuum levels the narrow lumens of the irrigating choppers that limits the max vacuum levels

((Both ICE and CASE systems and Both ICE and CASE systems and Cruise Control system allows us to use Cruise Control system allows us to use higher vacuum settings by controlling post occlusion surges 2)higher vacuum settings by controlling post occlusion surges 2)

the increase risk of corneal burn (3), the increase risk of corneal burn (3), (The risk is low if the phaco device and (The risk is low if the phaco device and the settings were appropriate for this surgery)the settings were appropriate for this surgery)

The safety and efficacy of bimanual MICS increases by the aid of cruise The safety and efficacy of bimanual MICS increases by the aid of cruise control system which provides higher vacuum, less US energy and less control system which provides higher vacuum, less US energy and less turbulance.turbulance.

1.1. Fine H, Hoffman RS, Packer M. Optimizing refractive lens exchange with bimanual Fine H, Hoffman RS, Packer M. Optimizing refractive lens exchange with bimanual microincisiion phacoemulsification. J Cataract Refractive Surg 2004; 30:550-554microincisiion phacoemulsification. J Cataract Refractive Surg 2004; 30:550-554

2.2. Chang D.F. 400 mmHg high vacuum bimanual phaco attainable with Staar Cruise Chang D.F. 400 mmHg high vacuum bimanual phaco attainable with Staar Cruise Control device. J Cataract Refractive Surg 2004; 30:932-933Control device. J Cataract Refractive Surg 2004; 30:932-933

3.3. William Soscia et all. Microphacoemulsification with Whitestar, A wound temperature William Soscia et all. Microphacoemulsification with Whitestar, A wound temperature study. J Cataract Refractive Surg 2002; 28:1044-1046study. J Cataract Refractive Surg 2002; 28:1044-1046

DISCUSSIONDISCUSSION

The Cruise Control was designed to reduce postocclusion surge with The Cruise Control was designed to reduce postocclusion surge with standard phaco instrumentation. However, its ideal application is with standard phaco instrumentation. However, its ideal application is with bimanual phaco, in which more limited irrigation inflow has otherwise bimanual phaco, in which more limited irrigation inflow has otherwise prevented the safe use of high vacuum settings from surge.prevented the safe use of high vacuum settings from surge.

The device consists of a 2 cm flow-restricting segment with a 0.3 mm The device consists of a 2 cm flow-restricting segment with a 0.3 mm internal lumen. It is positioned behind a mesh filter that traps emulsified internal lumen. It is positioned behind a mesh filter that traps emulsified nuclear material before it can clog the flow restrictor.nuclear material before it can clog the flow restrictor.

1.1. Chang DF. Correspondance. 400 mm Hg High-Vacuum Bimanual Phaco Attainable Chang DF. Correspondance. 400 mm Hg High-Vacuum Bimanual Phaco Attainable with the Staar Cruise Control Device. 2004;30(4):932-933with the Staar Cruise Control Device. 2004;30(4):932-933

400 mm Hg high-vacuum bimanual 400 mm Hg high-vacuum bimanual phaco attainable with this device. (1)phaco attainable with this device. (1)

Up to 300 mm Hg vacuum was used Up to 300 mm Hg vacuum was used in G 1, the operations performed in G 1, the operations performed safely without any complication.safely without any complication.

WHITESTARWHITESTAR ICE ICE AND CASE AND CASE TTECHNOLOGYECHNOLOGY

Kick seperates nucleus from phaco tip and creates a microspace thus Kick seperates nucleus from phaco tip and creates a microspace thus increase cavitationincrease cavitation

CASE is an occlusion mode technology which senses occlusion breaks, CASE is an occlusion mode technology which senses occlusion breaks, reverses the pumping system within 26 miliseconds thus decreases the reverses the pumping system within 26 miliseconds thus decreases the risk of surge and anterior cahmber insatbility in high vaccum settingsrisk of surge and anterior cahmber insatbility in high vaccum settings

DISCUSSION

DISCUSSIONDISCUSSIONIn recent years, damage to corneal endothelial cells during In recent years, damage to corneal endothelial cells during cataract extraction has been minimized as a result of better cataract extraction has been minimized as a result of better instrumentation, newer viscoelastic materials, and improved instrumentation, newer viscoelastic materials, and improved surgical techniques which aims to reduce phaco time (1).surgical techniques which aims to reduce phaco time (1).Studies report endothelial cell loss rates from 4% to 15% Studies report endothelial cell loss rates from 4% to 15% after phacoemulsification by experienced surgeons (2,3)after phacoemulsification by experienced surgeons (2,3)The 5.7% and 5The 5.7% and 5.2.2% of mean endothelial cell losses % of mean endothelial cell losses demonstrated the safety of the surgeries performed in hard demonstrated the safety of the surgeries performed in hard cataracts.cataracts. Both systems give us to ability to perform MICS in Both systems give us to ability to perform MICS in hard cataractshard cataracts

1.1. Holzer MP, Tetz MR, Auffarth GU, et al. Effect of Healon5 and 4 other viscoelastic Holzer MP, Tetz MR, Auffarth GU, et al. Effect of Healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery. substances on intraocular pressure and endothelium after cataract surgery. J Cataract J Cataract Refract SurgRefract Surg. 2001;27:213-218. 2001;27:213-218

2.2. Kosrirukvongs P, Slade SG, Berkeley RG. Corneal endothelial changes after divide Kosrirukvongs P, Slade SG, Berkeley RG. Corneal endothelial changes after divide and conquer versus chip and flip phacoemulsification. and conquer versus chip and flip phacoemulsification. J Cataract Refract SurgJ Cataract Refract Surg. . 1997;23:1006-10121997;23:1006-1012

3.3. Zetterström C, Laurell C-G. Comparison of endothelial cell loss and Zetterström C, Laurell C-G. Comparison of endothelial cell loss and phacoemulsification energy during endocapsular phacoemulsification surgery. phacoemulsification energy during endocapsular phacoemulsification surgery. J J Cataract Refract SurgCataract Refract Surg. 1995;21:55-58 . 1995;21:55-58

CONCLUSIONSCONCLUSIONS

The Cruise Control device gives us the ability to The Cruise Control device gives us the ability to perform MICS with higher vacuum settings without perform MICS with higher vacuum settings without affecting the safety of the operations.affecting the safety of the operations.

Modern phaco systems give us the ability to use Modern phaco systems give us the ability to use sleeveless, bare phaco tips from very small sleeveless, bare phaco tips from very small corneal incisions.corneal incisions.

By the aid of ICE and CASE settings, it is possible By the aid of ICE and CASE settings, it is possible to use higher vacuum settings and less US power to use higher vacuum settings and less US power without cruise control system.without cruise control system.