Microcoaxial phaco using 1 Microcoaxial phaco using 1.8mm incisions: comparison of two machines and IOL systems Richard Packard Windsor England Consultant for Alcon, AMO and Bausch and Lomb

Reasons for making incisions smaller Less leakage and therefore better controlled surgery Minimal if any induced astigmatism Faster rehabilitation visually for the patient Safer more rapidly healing wounds Because we can!

3.2mm 2.5mm 2.2mm 1.8mm

Microincisions with coaxial give: Protected wounds due to sleeve Less changes in technique and equipment than B-MICS Ability to use established IOL technology Minimal astigmatism

What do we need for C-MICS Wounds and therefore knives that match instrumentation Microsurgical capsulorhexis forceps New sleeves that are thin and allow enough fluid passage Thinner phaco tips? Understanding hydrodissection with microincisions No change in cataract removal techniques Phaco machines with appropriate power modulation and excellent fluidics IOLs capable of being injected with wound assistance through unopened Co-MICS incisions

Incisions for 1.8mm C-MICS

Capsulorhexis and hydrosteps and tip insertion for 1.8mm C-MICS

Stellaris System Overview EQ Fluidics equalises fluidic dynamics for solid chamber stability in vacuum or flow modes Ergonomic six crystal handpiece and tubing for efficient cutting and smooth removal of the nucleus in all techniques CustomControl™ Software II for customisable power modulation for all cataract grades Wireless Dual Linear foot pedal for instantaneous surgeon control of aspiration and ultrasound Sleek and ergonomically designed for operating room efficiency Modular design customisable to both EQ Fluidics options, the Advanced Flow Module or Vacuum Fluidics Module, plus all future upgrades

Stellaris EQ Fluidics Management Technology EQualising aspiration and irrigation for unsurpassed safety, efficiency and predictability in either flow or vacuum modes for solid chamber stability throughout the procedure EQ Advanced Flow Module (AFM) EQ Vacuum Fluidics Module (VFM) AFM is Advanced Flow Module - for Flow or Vacuum characteristics; VFM is Vacuum fluidics module Dr. Lindstrom – EQ Fluidics stands for B&L brand of fluidics technology. It stands for Equal, as in equal or balanced control of flow and aspiration. In the system, EQ Fluidics refers to both vacuum and flow/vacuum modules. Single module allows surgeons to toggle intra-operatively between flow and vacuum modes; flow for sculpting, vacuum for capsule polishing and I/A Latest generation vacuum fluidics with StableChamber tubing delivers exceptional accuracy and efficiency for MICS

INFINITITM Vision System Tri-modal AquaLaseTM OzilTM Improved Traditional Ultrasound Fluidics User Interface Ergonomics

Fluidic Management System Pump roller interface Vent valve interface Irrigation pinch valve Infusion pressure membrane Vacuum Pressure Sensor IntrepidTM low compression tubing

MICS tip and sleeve for 1.8mm surgery with B and L Stellaris Straight MICS tip 30 degree bevel 0.9mm at widest 0.5mm internal diameter

Mini-flared tip and Nano sleeve for 1.8mm surgery with Alcon Infiniti Curved 45 degree mini-flared tip 0.9mm at widest 0.57mm internal diameter

Stellaris Handpiece - efficient cutting Increased stroke length for efficient cutting of the nucleus Tighter, more focused and consistent delivery of stroke CustomControl™ II Software for customisable, programmable wavefront power modulations for all techniques

Translates = about 1/3 of thermal dissipation OzilTM technology Torsional (side) stroke at tip end (action) -oscillations occur at tip/hub/horn junction -distal end of Kelman tip exhibits a “side to side” displacement due to tip geometry More Efficient Cutting with 32KHz Torsional induces (“shearing” stress ) vs. Longitudinal u/s (“compression stress”) Longitudinal cuts on the “forward” stroke Torsional cuts both “right or left” = efficiency Translates = about 1/3 of thermal dissipation

Now that we have removed the nucleus which IOL can we use?

Akreos Microincision Lens Optimised for MICS Akreos Microincision Lens: Akreos MI60 Implantable through a 1.8 mm incision using a wound-assisted injection Biocompatible hydrophilic material with a proven record of safety, used in 2 million implantations since its introduction in 1998 The innovative haptic design ensures excellent 3-Dimensional stability of the IOL

AcrySof IQ* Aspheric Natural IOL (Alcon model SN60WF) Thinner aspheric optic design for 1.8mm insertion with wound assistance and D-cartridge Blue Light-Filtration AcrySof Single-Piece Platform Low PCO Material with 17years track record *IQ (Image Quality)

So how do they really compare? Both deliver 1.8mm surgery with early visual rehabilitation due to no induced astigmatism Both require specific knives, capsulorhexis forceps, phaco tips and sleeves Wound assisted insertion is mandatory Time will tell how the IOLs perform in the long term as far as PCO is concerned

Thank you