Next generation of phaco machines may be worth the upgrade

Other than the surgeon and the IOL, nothing might be more important in cataract surgery than the phacoemulsification machine.

It is the workhorse of one of the most commonly performed surgeries in the United States and the machine surgeons count on time after time.

“The phaco machine is the centerpiece of the OR, the hub of the wheel for all other technologies,” Healio | OSN Refractive Surgery Section Editor John P. Berdahl, MD, said. “You want the hub of your wheel to be the most reliable part of the wheel. If a spoke goes out, it will still be OK, but if you lose the hub, the wheel is done.”

There are a variety of surgical platforms available on the market, and although a surgeon might have a favorite, Brandon D. Ayres, MD, said it is important to not get caught in a rut and to try new things.

“Phaco machines are interesting, and people tend to have a favorite that they just like more rather than it’s actually better,” he said. “Surgeons don’t like change, and when you’ve done a surgery 10,000 times, any little change in your plan can cause a little bit of anxiety. People are quick to say that they don’t like something, but only because it’s new and not because they really don’t like it.”

With several next-generation phaco systems hitting the market, being receptive to change is more important than ever. While surgeons and practices need to do research and make the right choice for them, it is worth investing the time and dollars to have the best tool for such a common procedure, Berdahl said.

“In our practice, we believe in having the best technology available for our patients,” he said. “We start with the default position of do what we believe is best and then ask, ‘Can we make the best work?’ Almost always, we can.”

Berdahl said from a professional perspective, the prevalence of cataract surgery means that any small improvement has a big impact.

“The area under the curve is big, 5 million cataracts, and if we’re making some improvement on each one of them, that collective improvement is big,” he said. “I also ask myself the question, ‘What would I want if it was my eye?’ If it’s what I would want for my eye, we should try to find a way to get it, as long as we can make it work.”

Some surgeons are fortunate enough to practice at a center that has a variety of options. Healio | OSN Cataract Surgery Board Member Sumit “Sam” Garg, MD, said a big academic practice like his at UC Irvine has machines from multiple manufacturers to allow a variety of experiences and exposures for trainees.

“The normal life cycle for these machines is somewhere between 7 and 10 years,” he said. “Somewhere in that range, companies will continue to upgrade, whether it’s fluidics, the actual hardware, the sensing technologies, the computer or new features that may come out in that sort of cadence. We try to take a look at whatever is on the market, do some demos and get a consensus on where we want to go.”

Unity

One of the newest machines is the Alcon Unity, which comes as a stand-alone cataract system or a combined vitreoretinal cataract system. The systems received FDA 510(k) clearance in June, and Alcon is aiming for a 2025 commercial launch.

Berdahl said he was involved in some early clinical trials and has been impressed. Even in the early stages of using the system, it was a clear improvement over existing technology.

“We’re currently using the Centurion (Alcon), and the Centurion is a great machine, but I would say the Unity is an improvement on what we were using previously,” he said. “The three biggest factors for that improvement are efficiency, stability and usability for our team.”

Alcon is currently collecting real-world feedback from surgeons before Unity’s launch. So far, Berdahl said his experience has been positive.

Top on his list is improved safety due to surge mitigation.

“You’re able to detect eye pressure quicker and respond to that quicker,” he said. “For efficiency, they’ve introduced something they’re calling 4D phaco. That is the movement of the phaco tip in what appears to be a random pattern. Actually, it is a longer repeat pattern that keeps the piece of the cataract on the tip. It doesn’t seem to blow pieces off the cataract or into the angle as much.”

The Unity system is a replacement for not only the Centurion cataract system but also the Constellation vitreoretinal system (Alcon). Alcon estimated that it is targeting a combined 28,000 devices for replacement with the Unity system over the next 10 years.

The Unity system is also designed to be easier for staff to prepare for surgery and make the process more efficient, Berdahl said.

“The tray is bigger. The lighting is better. The ability to get the tubing primed is faster and requires fewer steps. There is a built-in way to keep the cords out of the wheels, and all these kinds of blocking and tackling aspects are being emphasized,” he said. “It’s a highly engineered machine that makes it seemingly easier, faster, more efficient and more stable to remove a cataract.”

Stellaris Elite

Another next-generation option is the Bausch + Lomb Stellaris Elite system. Barry S. Seibel, MD, said he has been using the Stellaris since it was first introduced and appreciates the features it provides as well as its surgical performance.

Adaptive fluidics through dual linear pedal control has had the greatest impact on his surgeries. The ergonomic pedal control has provided a major advantage when it comes to keeping the chamber stable during surgery.

Seibel shared how he performs a stop-and-chop technique with the Stellaris. First, he buries the phaco tip to engage the hemi-nucleus with a moderate amount of vacuum and ultrasound. From there, he wants to discontinue ultrasound while increasing vacuum for a strong grip for chopping.

“With the standard pedal, that’s difficult to finesse rising just out of position three but just into position two,” he said. “Some pedals have a detent or vibration, but it can still be difficult. With dual linear, it’s much easier because the pedal can be yawed (moved sideways) completely to the left while adjusting vacuum in pitch (vertical movement).”

Once he has the hemi-nucleus entrapped with high vacuum and has started the horizontal chop, he moves to a lower more moderate vacuum that is more appropriate for the subsequent step of carouseling phacoaspiration. A standard pedal would typically force the surgeon to deal with the higher than required vacuum level used for chopping when entering ultrasound and produce more post-occlusion surge and chamber instability as compared with the simultaneously moderate levels readily achievable with a dual linear pedal.

“A standard pedal that all surgeons are familiar with operates in an up or down motion (pitch), where they have position zero and ranges one, two and three for pressurization, fluidics (vacuum and/or flow) and then ultrasound, respectively,” he said. “The problem is, if you’re doing more advanced techniques like phaco chop, which is growing in popularity, it’s advantageous to be able to finesse these parameters independently; this if facilitated in dual lineal pedal control by separating range two (fluidics) and range three (ultrasound) into independent pedal movements (pitch and yaw).”

Seibel said the Stellaris provides enhanced sensitivity and control for the whole surgery.

“The benefit to me is just one of constant control over the delicate anterior chamber environment with fewer chamber fluctuations and more assuredness of chamber depth and stability,” he said. “With standard pedals, there are workarounds, but you need to create another memory for segment removal that had that lower level of vacuum with more chamber stability than the higher level of vacuum I needed for chopping. It’s just more awkward to go back and forth between memory settings than to dynamically and spontaneously finesse the control with the dual linear pedal.”

Seibel said the Stellaris’ pressurized infusion proactively keeps the chamber stable and allows surgeons to map out the amount of infusion according to the amount of vacuum.

“If you have an occlusion, you’re increasing the potential for a post-occlusion surge,” he said. “What the Stellaris Elite does through this pressurized infusion is keep ahead of that curve. The more vacuum you’re commanding could lead to a higher surge. Adaptive fluidics proportionately increases the amount of pressurized infusion to more likely mitigate a potential surge. Pressurized infusion is something that our posterior segment colleagues have done for years. I’m glad to see the anterior segment community catching up to that.”

Veritas

While he has access to several machines, Garg said the Johnson & Johnson Vision Veritas system has been a critical tool for his practice because of its versatility. Because it is a dual pump machine, surgeons can use it whether they prefer a Venturi or peristaltic pump.

“The other benefit is that you’re not tied to a specific needle type,” he said. “You can use a curve tip, a straight tip or a bevel tip — really, anything that you want.”

Like the Stellaris, the Veritas has pressurized infusion aiding in efficiency and chamber stability, Garg said. As with other newer-generation phaco machines, it also has the ability to detect occlusion breaks more quickly, providing surgeons with the opportunity to avoid post-occlusion surge.

“It’s pretty rare to see a phaco wound burn, especially if you’re occluded, because of this sensing,” he said. “You also get better chamber stability, and because of the optimized tubing and pressurized infusion, we’re not seeing instability of the chamber.”

Garg said Veritas and other newer-generation machines allow for more varied ways to deliver phaco more efficiently with less energy in the eye.

These machines also offer better user interfaces, keeping staff as well as the surgeon in mind. Garg said factors such as setup, tuning and troubleshooting have always been important for using phaco machines.

“I would argue that the surgeon is a less important part of the user interface, and for the staff, it’s more important,” he said. “All the machines have gotten better with respect to that as well. The interface has become more user-friendly for staff. To know where you are in the case and to move between different aspects of the case are more streamlined compared to some of our more traditional machines.”

Garg said the Veritas also features ergonomic improvements. While reducing weight and improving balance are good for the surgeon, these advances also show just how much thought and engineering went into the system.

“You don’t necessarily think about these engineers who spend hours and weeks and months on trying to make things incrementally better,” he said. “Going from early-generation phaco machines to machines from 10 to 15 years ago, you saw a pretty dramatic difference in the technology just because there was an opportunity to make those improvements. Now, we’re sort of at a point where the differences are much more subtle. There are improvements, but it’s not as marked as it used to be. However, they are looking at different ways of approaching phaco, new technologies for safety and trying to decrease frequent pain points of surgeons and staff.”

Quatera

Ayres said the Zeiss Quatera 700 system is the best out-of-the-box phaco machine he has ever used.

“It felt comfortable and had a very familiar kind of feel,” he said. “It made the transition to a new machine really easy.”

Ayres likes being able to use different machines, but sometimes, he feels like one offers a performance edge over the others. He said that the Quatera makes surgery followable, with the cataract pieces coming to the tip easily and quickly.

“I like things that move quickly in the OR,” he said. “Now that we’ve had some experience under our belt with the Quatera, we have started to notice that our cases are going faster. We’re probably saving 30 or 40 seconds per case. That’s how noticeable the efficiency of the machine is.”

The system has also been easy to integrate into the operating room, Ayres said. Something as simple as the surgical video appearing on the Quatera screen has made the surgical process much easier.

“You can set it up so the scrub tech and circulating nurse can see what you’re doing without a problem,” he said. “Simple things like that can make a big difference with your flow in the OR.”

Ayres said he has not taken the Quatera down to the lowest infusion pressure yet. He prefers to have more time with a machine to become more comfortable with its high speeds first.

“You’ve got to make sure you’ve got a well-known system before you start pushing pressures low,” he said. “I think the next era of phaco is going to be trying to do cataract surgery at near physiologic intraoperative pressure. High speed and low pressure involve a lot of movement, and as we get more comfortable, we probably could lower the IOP, but I just wasn’t ready to take that dive yet. Even at our normal IOP, the chamber stability with Quatera is top notch.”

Summing-up

No matter which machine a surgeon or practice chooses, these experts believe that the upgrade can be worth it.

“If you don’t push yourself just a little bit out of the comfort zone, you’re never going to really progress,” Ayres said. “That’s true with lens implants, it’s true with surgical techniques, and it’s true with your phaco machines. Sometimes, your surgical technique will just match up great with a particular machine, and if you don’t try a different machine, then you might miss an opportunity for something that works really well for you.”

Garg said most companies will bring in surgeons to give demonstrations on a new machine and help them learn. This can be a good opportunity to see if a system resonates and makes cases easier to perform.

“As surgeons, it’s really easy to stay stagnant or stick in the way we were trained or in the way that works for us now,” he said. “But a lot of these machines are designed to try to make things faster, safer and more efficient. You have to be open to changing a little bit.”

The decision to upgrade is not always an easy call, Berdahl said. However, if a practice is in the market for a new machine, the surgeon should want the best possible choice.

“These products have a life cycle of about 10 years, so depending on where you are in that cycle will be a factor in when you decide to upgrade,” he said. “I just love that we’ve got a profession that continues to raise the bar.”

• Reference:
• Alcon’s latest equipment breakthrough technologies, Unity VCS and Unity CS, receive U.S. FDA 510(k) clearance. https://www.alcon.com/media-release/alcons-latest-equipment-breakthrough-technologies-unity-vcs-and-unity-cs-receive-us/. Published June 24, 2024. Accessed Nov. 20, 2024.

• For more information:
• Brandon D. Ayres, MD, of Wills Eye Hospital, can be reached at brandonayres@me.com.
• John P. Berdahl, MD, of Vance Thompson Vision in Sioux Falls, South Dakota, can be reached at john.berdahl@vancethompsonvision.com.
• Sumit “Sam” Garg, MD, of the University of California, Irvine, can be reached at gargs@hs.uci.edu.
• Barry S. Seibel, MD, of Seibel Vision Surgery in Los Angeles, can be reached at idoc2020@me.com.

Click here to read perspective from Neda Shamie, MD.

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Source:
Healio Interviews

Disclosures:
Ayres reports consulting for Zeiss. Berdahl reports consulting for Alcon. Garg reports consulting for Johnson & Johnson Vision. Seibel reports consulting for Bausch + Lomb.

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