Refractive Lens Surgery

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the sonic tip moves back and forth without changing its dimensional length (Fig. 24.3). The tip of an ultrasonic handpiece can easily exceed 500° Celsius in a few seconds, while the tip of the Wave handpiece in sonic mode barely generates any frictional heat, as intermolecular friction is eliminated (Fig. 24.4). In addition, the sonic tip does not generate cavitational effects and thus true fragmentation, rather than emulsification or vaporization, of the lens material takes place. This adds more precision and predictability in grooving or chopping and less likelihood for corneal endothelial compromise or incisional burns. The most amazing aspect of the sonic technology is that the same handpiece and tip can be utilized for both sonic and ultrasonic modes. The surgeon can easily alternate between the two modes using a toggle switch on the foot pedal when more or less energy is required. The modes can also be used simultaneously with varying percentages of both sonic and ultrasonic energy. We have found that we can use the same chopping cataract extraction technique [4] in sonic mode as we do in ultrasonic mode, with no discernible difference in efficiency. The ideal phacoemulsification machine should offer the highest levels of vacuum possible with total anterior chamber stability. The Staar Wave moves one step closer to this ideal with the advent of the SuperVac tubing (Fig. 24.5). SuperVac tubing increases vacuum capability to up to 650 mmHg while significantly increasing chamber stability. The key to chamber maintenance is to achieve a positive fluid balance, which is the difference between infusion flow and aspiration flow. When occlusion is broken, vacuum previously built in the aspiration line generates a high aspiration flow that can be higher than the infusion flow. This results in anterior chamber instability. The coiled SuperVac tubing limits surge flow resulting from occlusion breakage in a dynamic way. The continuous change in direction of flow through the coiled tubing increases resistance through the tubing at Chapter 24 The Staar Sonic Wave 225 high flow rates, such as upon clearance of occlusion of the tip (Fig. 24.6). This effect only takes place at high flow rates (greater than 50 cc/min). The fluid resistance of the Super- Vac tubing increases as a function of flow and unoccluded flow is not restricted. Staar has also recently released its cruisecontrol device, which has a similar end result of increasing vacuum capability while maintaining anterior chamber stability. The cruise control (Fig. 24.7) is inserted between the phacoemulsification handpiece and the aspiration line. It has a small port at the end attached to the aspiration line to restrict flow when high flow rates are threatened, such as during occlusion breakage. A cylindrical mesh within the cruise-control tubing is designed to capture all lens material before it reaches the restricted port, thus occlusion of the port is prevented. The mesh is designed with enough surface area to guarantee that aspiration fluid will always pass through the device. This device is especially important during bimanual phacoemulsification, as the anterior chambers of eyes undergoing this technique are susceptible to chamber instability if postocclusion surge develops. 24.3 New User Interface Perhaps the most advanced feature on the Wave is its new user interface. The Wave Powertouch computer interface mounts onto the Staar cart above the phacoemulsification console. The touchscreen technology allows the user to control the surgical settings by touching parameter controls on the screen. The interface utilizes Windows software and is capable of capturing digitally compressed video displaying the image live on the monitor screen. A 6-gigabyte hard disk can store up to 8 hours of video without the need for VHS tapes. The most useful and educational aspect of the Wave interface is the event list, which displays multiple data graphs to the right of the
226 R.S. Hoffman · I.H. Fine · M. Packer Fig. 24.8. Wave video overlay demonstrating multiple data graphs to the right with power, vacuum, flow, and theoretical tip temperature parameters surgical video (Fig. 24.8). The event list displays recorded power, vacuum, flow, theoretical tip temperature, and risk factor for incisional burns on a constantly updated timeline. The vertical line in each graph represents the actual time event occurring on the video image. Surgical events to the left of the line represent past events, while data to the right of the line represent future events ready to occur. A CD-Rom recorder can be used to transfer surgical video and data graphs from the hard drive to a writable CD. This allows the surgeon to view each case on any Windows home or office computer or use the images for presentations. The ability to review surgical parameters on a timeline as the video image is being displayed allows surgeons to analyze unexpected surgical events as they are about to occur in a recorded surgical case. This information can then be used to adjust parameters or surgical technique to avoid these pitfalls in future cases. Staar eventually plans to transmit live surgical cases over the internet so that surgeons anywhere in the world can log on and watch a selected surgeon demonstrate his or her technique with real-time surgical parameter display. 24.4 Conclusion The Staar Wave is one the most advanced phacoemulsification systems available today. The use of sonic rather than ultrasonic energy for the extraction of cataracts represents a major advancement for increasing the safety of cataract surgery. Sonic mode can be used by itself or in combination with ultrasonic energy, allowing for the removal of all lens densities with the least amount of energy delivered into the eye. SuperVac tubing allows higher levels of vacuum to be used for extraction with increased chamber stability by nature of the resistance of this tubing to high flow rates when occlusion is broken. Finally, the addition of advanced video and computer technology for recording and reviewing surgical images and parameters will allow surgeons further to improve their techniques and the techniques of their colleagues through better communication and teaching. References 1. Fine IH (1998) The choo-choo chop and flip phacoemulsification technique. Operative Techn Cataract Refract Surg 1:61–65 2. Fine IH, Packer M, Hoffman RS (2001) The use of power modulations in phacoemulsification of cataracts: the choo-choo chop and flip phacoemulsification technique. J Cataract Refract Surg 21:188–197 3. Fine IH (1997) Special report to ASCRS members: phacoemulsification incision burns. Letter to American Society of Cataract and <strong>Refractive</strong> <strong>Surgery</strong> members 4. Majid MA, Sharma MK, Harding SP (1998) Corneoscleral burn during phacoemulsification surgery. J Cataract Refract Surg 24:1413– 1415. 5. Sugar A, Schertzer RM (1999) Clinical course of phacoemulsification wound burns. J Cataract Refract Surg 25:688–692
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Refractive Lens Surgery I. H. Fine
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Editors I. Howard Fine, MD Mark Pac
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Preface The first recorded time a h
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X Contents Chapter 14 AcrySof ReSTO
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Contributors Jorge L. Alio, MD, PhD
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1 The Crystalline Lens as a Target
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2 CORE MESSAGES Refractive Lens Exc
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na that have been observed with som
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piration through two separate incis
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6 R.S. Hoffman · I.H. Fine · M. P
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8 R.S. Hoffman · I.H. Fine · M. P
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10 R.S. Hoffman · I.H. Fine · M.
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12 M. Packer · I.H. Fine · R.S. H
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22 J.T. Holladay 4.1 Introduction T
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24 J.T. Holladay but only seven pre
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26 J.T. Holladay from morning to ni
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28 J.T. Holladay 4.3.2.2.3 Corneal
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30 J.T. Holladay rienced this condi
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32 J.T. Holladay many of these pati
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34 J.T. Holladay IOL eRx V 1336 =
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36 J.T. Holladay raised. A more tho
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38 J.T. Holladay rior segment laser
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40 D.D. Koch · L.Wang corneal refr
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42 D.D. Koch · L.Wang Table 5.1. M
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44 D.D. Koch · L.Wang Fig. 5.4. Nu
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46 D.D. Koch · L.Wang Fig. 5.5. Ce
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48 D.D. Koch · L.Wang ∑ Double-K
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50 L.D. Nichamin surgeon the abilit
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52 L.D. Nichamin Table 6.1. The Nic
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54 L.D. Nichamin 3.2 mm, its neglig
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56 L.D. Nichamin Fig. 6.4. The Nich
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58 L.D. Nichamin References 1. Anon
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60 S. Bylsma aphakic state. In cont
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62 S. Bylsma length),underwent full
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64 S. Bylsma K-Astigmatism
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66 S. Bylsma STIOL in the reversed
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68 S. Bylsma about the dynamics at
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8 Correction of Keratometric Astigm
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Fig. 8.2. AcrySof toric IOL implant
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Fig. 8.3. Mean absolute residual cy
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References 1. Hoffer KJ (1980) Biom
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10 The Eyeonics Crystalens Steven J
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Fig. 10.3. Under binocular conditio
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Fig. 10.6. Anterior movement of the
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Fig. 10.7. One- and 3-year data fro
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10.6 Postoperative Considerations C
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10. Dell SJ (2004) Objective eviden
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100 N.X. Nguyen · A. Langenbucher
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12 CORE MESSAGES Synchrony IOL H. B
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Fig. 12.1. The single-piece silicon
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12.5 Clinical Results Clinical tria
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Fig. 12.6. Retroillumination photog
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References 1. Fisher RF (1973) Pres
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124 F.M. Sarfarazi 13.1 The Nature
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126 F.M. Sarfarazi Fig. 13.4. Lens
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128 F.M. Sarfarazi Fig. 13.5. Mecha
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130 F.M. Sarfarazi Fig. 13.9. Secon
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132 F.M. Sarfarazi Fig. 13.14. Sche
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134 F.M. Sarfarazi Fig. 13.18. Work
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136 F.M. Sarfarazi References 1. Ma
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138 A. Mirshahi · E.Terzi · T. Ko
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15 The Tecnis Multifocal IOL Mark P
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Fig. 15.1. The Alcon AcrySof multif
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Fig. 15.4. Multifocal vs. monofocal
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16 Blue-Light-Filtering Intraocular
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Fig. 16.2. Cultured human RPE cells
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tion to benefiting from less exposu
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16.7 Blue-Light-Filtering IOLs and
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15. Marshall J, Mellerio J, Palmer
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17 CORE MESSAGES The Light-Adjustab
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Fig. 17.2 a-c. Cross-sectional sche
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17.4 Animal Studies Dr. Nick Mamali
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Fig. 17.8. A laser interferogram (l
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enhanced visual function that remai
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