What's New in Cataract Instruments?
What's New in Cataract Instruments?
Surgeons play key role in advancing innovation.
BY JERRY HELZNER, SENIOR EDITOR
Almost any instrument used in cataract surgery today began as an idea or raw concept brought to an instrument company by a surgeon. That fact alone speaks to the innovative mindset of cataract surgeons.
John Bee, president of Rhein Medical, Tampa, Fla., probably knows as much about the inventiveness of ophthalmologists than anyone. His company has successfully commercialized scores of ophthalmic devices, almost all of which bear the name of the inventor. Many of these devices have now been adopted into the everyday practice of ophthalmology.
"About 99% of the time, the surgeon comes to us with a concept or drawing and a description of the application. We will then work with the surgeon to create a prototype," says Bee. "Sometimes we explore the concept with other surgeons to determine if they believe such a product could help them."
Bee says that eye surgeons are especially innovative because they are passionate about preserving sight. In addition, they are constantly being confronted by new technologies that in turn create opportunities for individual surgeons to improve procedures.
"The new technologies spur their sense of innovation," says Bee.
A cataract surgeon, who prefers to be quoted anonymously, has a less lofty view of the motivation for invention.
"The truth is that we are so 'Type A' and so driven that we will attempt to create an instrument to improve a procedure, even if the improvement is just incremental," he says. "But for patients that's a good thing."
In any case, this article will describe some of the newest and most innovative instruments for cataract surgery, many of which have come to market in the past few months. The companies represented will be listed in alphabetical order.
Accutome (www.accutome.com) recently introduced the Donnenfeld Irrigating Positioner or "DIP," which is designed to assist in facilitating toric IOL placement.
"Dr. Donnenfeld has joked and called it his "Triton," says Jim O'Connor, marketing manager of Accutome. "This instrument opens the capsular bag and rotates the toric IOL into place."
O'Connor says sales have been "great since we introduced the instrument in January." He says the DIP is the first instrument designed specifically for toric IOL placement.
Another new Accutome product is The Devgan Axis Marker, which was developed through the combined efforts of company designers and Uday Devgan, MD, after seeing an opportunity for a better way to mark the axis prior to toric IOL surgery.
"With the Devgan Axis Marker, the surgeon eliminates the need to mark the patient in the operating room and can mark the patient preoperatively using anterior stromal puncture marks," says O'Connor. "This is a technique developed by Byron Stratas, MD, and Dr. Devgan that is really gaining in popularity."
O'Connor notes that new tools for astigmatism management continue to be in demand, with Accutome constantly working on ideas for new instruments that help the surgeon perform LRIs or implant toric IOLs.
The Devgan Axis Marker from Accutome offers a new way to mark the axis prior to toric IOL implantation.
"Sharps safety is also another big trend we are following," says O'Connor. Accutome does not carry a guarded handle blade but instead has designed an "AccuSafe" case for the company's AccuSharp line of disposable metal blades. Each blade comes individually packaged in the plastic case to ensure sharpness prior to surgery and provide sharps protection after the incision has been made.
Finally, as incision sizes continue to get smaller, Accutome has seen a dramatic increase in sales of 2.2 mm to 2.4 mm diamond and steel knives.
ASICO (www.asico.com) has launched The Miyoshi Dual Flow Hydrodissection Cannula. "The port design allows me to perform hydrodissection immediately under the anterior equatorial capsule," says Teruyuki Miyoshi, MD, of Fukuyama, Japan. "Complete hydrodissection can be achieved the very first time with the added advantage of operating on only minimal power.
The Miyoshi Hydrodissection Cannula (top) and the Kraff-Utratas Capsularhexis Forceps were recently introduced by ASICO.
When using the cannula, it is important to push the nucleus down when withdrawing from the anterior chamber to facilitate perfect hydrodissection, even close to the wound."
ASICO has also recently introduced the Espiritu-Caparas Chopper.
"It made perfect sense for us to have our favorite 'second instruments' in one piece, so we developed the Espiritu-Caparas Chopper," says Ramon G. Espiritu, MD, of Manila, Philippines. "We use the spatula to fixate the eye through the sideport incision, manipulate and redirect lens material, and, by positioning it underneath the phaco tip, protect the posterior capsule. The ideal curve, length and multiple cutting edges of the Verges-style chopper on the other end makes it a truly versatile tool."
Finally, ASICO's Kraff-Utratas Capsularhexis Forceps have been modified for microcoaxial cataract surgery. With a much thinner profile, jaws open much wider without stretching the microincision. Sharp tips can be used as cystotome while the jaws are recessed to prevent iris pickup. The 1.0 mm laser lines aid in measuring capsulorhexis.
"These forceps are very easy to use through a 2.2 mm incision," says ASICO.
BD Ophthalmic (www.bd.com) has introduced BD Atomic Edge Accurate Depth Knives for LRI.
Designed especially for performing LRIs, BD says single-use Atomic Edge silicon knives are equal in performance to diamond blades, and superior to diamonds in such aspects as consistent and precise blade exposure, single-use convenience, lower acquisition cost and elimination of maintenance costs and the need for calibration.
Blade exposures currently available are 550 μm and 600 μm, with additional blade exposures planned for this line.
Paul Koch, MD, says Atomic Edge knives "are incredibly sharp and create an incision with virtually no epithelial drag." Dr. Koch finds the knives very similar in performance to diamond blades.
In addition, BD Ophthalmic now offers the Visitec range of forceps, scissors, manipulators and other single-use microsurgical instruments in stainless steel as well as with plastic handles and stainless steel tips. BD says Visitec instruments completely eliminate the risks of infection that are present even when instruments are sterilized properly. The company notes that France has adopted single-use instruments as the standard for infectious disease control in surgery.
BD Ophthalmic now offers an entire range of single-use microsurgical instruments in its Visitec line.
Says Randall Olson, MD: "As we, as surgeons, get ever busier, and the sterilization standards more restrictive, the price is high for any breakdown such as TASS or endophthalmitis infections. We need to examine the use of singleuse instruments as a better approach. I would recommend that single-use instruments be tried and evaluated as an alternative to reusable instruments in ophthalmic surgery."
Bausch & Lomb Storz (www.bauschsurgical.com) has launched the Wallace LRI Set. Designed by R. Bruce Wallace, III, MD, of Alexandria, La., Storz says this set is ideal for treating preoperative or residual surgical astigmatism, ensuring cylinder is kept to a minimum following cataract surgery. It is suggested when the surgeon prefers to perform astigmatism correction without the use of a laser or toric IOL.
The set consists of three instruments, including the Wallace Mendez Degree Gauge, a 0.12 mm Colibri Forceps and the Wallace LRI Diamond knife.
The Wallace Mendez Degree Gauge is designed for surgeons familiar with the use of a standard phoropter. It measures 0° to 180° twice in 10° increments with 10° interval marks.
The Colibri Forceps is used to stabilize the eye during the LRI technique. This instrument features 0.12 mm, 1 × 2 teeth and a serrated handle.
The Wallace LRI Diamond Knife features a single footplate that allows excellent visualization of the blade as it passes through corneal tissue. The handle is designed for finger rotation as the 600 μm preset blade follows the arcuate pattern of the limbus.
Storz has also introduced the Silverstein instrument set for MICS 1.8 mm surgery, designed by Steven Silverstein, MD, of Kansas City, Mo.
This set includes the Silverstein MICS 1.8 mm Capsulorhexis Forceps, a uniquely styled ultra-thin profile forceps that allows maximum maneuverability through a sub-2.0 mm incision without oarlocking or unnecessary distortion of the wound architecture during capsulorhexis. In addition, the 6.0 mm marks on the anterior blade surface allow the surgeon to create a consistent central capsulorhexis.
The Wallace LRI Set from B&L Storz provides three instruments for preoperative or residual astigmatic correction.
Also part of the set is an updated version of the Wiles Hydrodissection Cannula. Storz says this thin-profile, J-style cannula allows easy manipulation in and out of the sub-2.0 mm wound, while providing an adequate irrigating stream for both hydrodissection and hydrodelineation as well as subincisional cortical clean up.
The Silverstein Phaco Manipulator and Quick Chop has a chopper on one end and a spatulated paddle on the opposite end to accommodate any phaco technique or density of lens material.
In addition to the previously mentioned designs, the Silverstein set also includes a 1.8 mm diamond keratome, a 45-degree I/A tip with handpiece, a 27-gauge silicone capsule polisher and a 2.8 mm diamond keratome.
Crestpoint (www.crestpointmgt.com) launched the Geuder Osher Micro Scissors and Forceps line for microincision surgery at this year's ASCRS meeting. This modular set is specifically precision-designed for small-incision surgery and multi-meridional access, with the angulation of the multiple-option platforms offering easy access to an expanded range of meridia inside the eye.
Crestpoint says the instruments in this set provide exact cutting and secure grasping in both the horizontal and vertical planes. The forceps and scissors are color-coded (blue and gold) for ease in identification.
The Geuder Osher range from Crestpoint Management includes scissors and forceps for microincision surgery.
Crestpoint also introduced additions to the Mackool line of cataract surgery instruments, designed by Richard Mackool, MD. The latest additions are a capsulorrhexis forceps and speculum.
Katena (www.katena.com) introduces the MICS Trapezoidal Diamond Knife, which is designed for surgeons who prefer to perform phaco through a 2.1 mm incision and then widen the incision to 2.4 mm for insertion of the IOL. The knife features a gem quality, trapezoidal-shaped diamond blade with four cutting edges, measuring 2.1 mm at the shoulder and 2.4 mm at the base.
Katena has also launched the Ernest Micro Nucleus Cracker, a forceps designed for surgeons who utilize a nucleus-cracking technique through a microincision. It is identical to the original Ernest Nucleus Cracker, but with a modified cross-action mechanism. This modification allows the surgeon to crack the nucleus through a 2 mm incision without stretching the wound. The instrument features delicate, serrated paddle tips, which spread apart by compressing the forceps handle. A surgeon can easily divide a nucleus into smaller segments by inserting the delicate tips into a groove created with a phaco probe and cracking.
Katena now offers the MICS Trapezoidal Diamond Knife (left) and the double-ended Chang-Siebel Combination Chopper.
In addition, Katena now offers the Chang-Seibel Combination Chopper for soft to moderately dense nuclei. The double-end instrument features the Seibel Vertical Safety Chopper tip on one end and the Chang MicroFinger Horizontal Chopper tip on the other end.
The Seibel Chopper has a thin paddle-shaped design with a beveled edge along the curved, posterior tip. The curved beveled edge ensures that any capsule contact will be distributed over a larger surface area, thereby reducing the chance for inadvertent capsule rupture. Once the nucleus is fractured, the broad flat sides of the paddle aid in safely completing the division down to the posterior plate.
The Chang MicroFinger is used for horizontal chopping and features a "finger-shaped" tip with a defined inferior edge for nucleus division. By slipping the tip under the rhexis and hooking around the equator, the nucleus is divided horizontally as it is pulled centrally toward the phaco probe. It is also ideal for subdividing mobile quadrants into smaller fragments.
This instrument is offered in two models — for right- or left-hand use.
Moria (www.moria-surgical.com) recently launched the "One" range of disposable cataract instruments.
Nine of the instruments are available now and six more are planned for the future.
The current selection includes four types of forceps, a Sinskey hook, Lester manipulator, cyclodialysis spatula, phaco chopper and Kratz wire speculum. Future additions to the "One" line include a Thornton ring, McPherson forceps, Drysdale manipulator, Lieberman speculum, Vannas scissors and a needle holder.
Moria has introduced the "One" range of single-use instruments, with a total of 15 disposables planned for the set.
Moria says the single-use "One" line eliminates the possibility of infection that is present with reusable instruments. In addition, Moria says its disposable instruments meet increasingly stringent regulatory requirements, guarantee a precise, undamaged instrument for each procedure, end repair costs and provide a favorable cost/benefit ratio.
Rhein (www.rheinmedical.com) notes that toric IOLs require precise alignment for optimal outcomes. Cyclotorsional errors can occur as the patient moves from the upright to the supine position. Rhein says its new markers help ensure correct axis placement in a simple and easy to use fashion.
Rhein Medical has recently launched the Dell Toric Market in both fixed (shown above) and swivel versions.
For the non-weighted instrument, Rhein offers the Dell Fixed Toric Lens Marker with Rotating Bezel. A rotating inner bezel automatically orients marks for the placement of a toric IOL in the correct meridian. While the patient is upright, an orientation mark is placed vertically on the conjunctiva. In surgery, the rotating inner bezel is set to the desired meridian while the instrument is positioned so that the vertical conjunctival mark is aligned with the 90 degree position on the outer bezel of the marker. The marking blades on the undersurface of the instrument will automatically mark the correct meridian when the cornea is indented.
For the weighted instrument, Rhein now offers the Dell Swivel Toric Lens Marker with Rotating Bezel.The marker is weighted so that correct horizontal orientation is assured. The rotating inner bezel automatically orients blades for corneal marks for placement of a toric IOL in the correct meridian. Designed for use with the patient upright immediately prior to surgery, the inner bezel is rotated to the desired meridian and the cornea is indented. The marking blades on the undersurface of the instrument will automatically place marks in the correct meridian.
New from Rumex (www.rumex.net) are the 2.0/2.3 mm Trapezoid Self-Diving Diamond Knife, the Inamura Capsulorrhexis Forceps featuring curved jaws (10 mm) with a maximum opening inside the eye of 2.0 mm, and the
Kershner One-Pinch Capsullorhexer, with micro jaws (with lock) 23 g, with cystotome tips. Rumex says this forceps has a reduced tip length for better maneuverability in the anterior chamber during capsulorrhexis. OM
Rumex is now offering two new types of forceps (top) and a trapezoid diamond knife.
Ophthamology Management, Issue: August 2009