1. TESTUPLOAD

2. TORSIONAL PHACOEMULSIFICATION In January 2006 Alcon Surgical incorporated Ozil torsional into the Infiniti Vision System. Unlike the conventional longitudinal phacoemulsification which emulsifies the lens with forward and backward movement of the phaco tip, Ozil torsional technology produces a side-to-side motion of the phaco tip. Efficiency is increased with this technology since it does not produce repulsion and breaks up the nucleus by shearing and not by the conventional jackhammer effect.

3. TORSIONAL PHACOEMULSIFICATION Straight Phaco Tip45 º Bent Phaco Tip Shearing effect increases with the use of bent tips.

4. OZil® IP (Intelligent Phaco) Total occlusion decreases the efficiency of torsional US by causing the lost of the optical shearing plane, generally combined torsional/longitudinal US mode was chosen for emulsification. Recently Intelligent Phaco (IP) upgrade which delivers a very small amount (short pulse) of longitudinal US just before the occlusion is complete, added to Ozil torsional technology to further increase its efficiency.

5. OZil® IP (Intelligent Phaco) OZil® IP does is avoid a complete occlusion of the tip and maintain the right shearing plane and keep the emulsification on going. Static, occluded or blocked tip impacts followability, allowing fragments to fall away from tip

6. The Study PURPOSE: To compare the safety and efficacy of microcoaxial phacoemulsification surgeries performed with Ozil Intelligent Phaco (IP) torsional mode and combined torsional/longitudinal ultrasound (US) mode using Infiniti Vision System.

7. METHODS Between January and May 2010 microcoaxial phacoemulsification with Ozil IP torsional mode (G1) was performed in 30 eyes of 30 patients and microcoaxial phacoemulsification with combined torsional/longitudinal US mode (G2) was performed in 30 eyes of 30 patients by using the Infiniti Vision System (Alcon Laboratories). O.9 mm 30-degree mini-flare 12-degree bent tip was used in all of the operations.. The intrepid ClearCut 2.2 mm dual-bevel metal keratome (Alcon) was used for 2.2 mm incisions.

8. METHODS Patients were examined for; Intraoperative complications, Intraoperative complications, Mean US times, Mean US times, Longitudinal US amplitudes Longitudinal US amplitudes Torsionel US amplitudes, Torsionel US amplitudes, Cummulative Dissipated Energy (CDE) Cummulative Dissipated Energy (CDE) Postoperative outcome measures were anterior chamber reactions, change in the corneal clarity, central corneal thickness (CCT), early uncorrected visual acuity (UCVA) and final best corrected visual acuity (BCVA). Postoperative outcome measures were anterior chamber reactions, change in the corneal clarity, central corneal thickness (CCT), early uncorrected visual acuity (UCVA) and final best corrected visual acuity (BCVA).

9. METHODS Anterior chamber reactions and Corneal edema were graded as Anterior Chamber Reactions: Anterior Chamber Reactions:None, Mild (1-3 cells in 16X field), Moderate (3-10 cells in 16X field), Severe Corneal edema Corneal edemaNone,Mild,Moderate,Severe

10. NUCLEUS GRADES 2,13 2,23 P=0,629 (P>0,05) Mean nucleus grades of the groups were similar.

11. Ozil IP Phaco 1 - Grooving Aspiration Vacuum Ozil IP Aspiration Vacuum Ozil IP 28 cc/min. 50 mmHg %80 28 cc/min. 50 mmHg %80 Linear Panel Linear Linear Panel Linear Phaco 2 - Chopping Aspiration Vacuum Ozil IP Aspiration Vacuum Ozil IP 32 cc/min. 330 %80 32 cc/min. 330 %80 Linear Linear Linear Linear Linear Linear IP pulse: 10% longitudinal torsional ratio. IP vacuum threshold: 95% of the maximum Pulse length: 10 ms. Torsionel/Longitudinal Phaco 1 - Grooving Aspiration Vacuum Ozil/Long. Aspiration Vacuum Ozil/Long. 28 cc/min. 50 mmHg %40-%60 28 cc/min. 50 mmHg %40-%60 Linear Panel Linear Linear Panel Linear Phaco 2 - Chopping Aspiration Vacuum Ozil/Long. Aspiration Vacuum Ozil/Long. 32 cc/min. 350 %40-%60 32 cc/min. 350 %40-%60 Linear Linear Linear Linear Linear Linear PARAMETERS

12. ENERGY PARAMETERS GROUP 1 (OZiL IP) Mean US Time: 1 min 21 sec (SD 35.56 sec) 1 min 21 sec (SD 35.56 sec) Mean longitudinal US amp: 0.55 (SD 0.49) 0.55 (SD 0.49) Mean torsionel US amp: 26.96 (SD 9.33) 26.96 (SD 9.33)CDE: 10.18 (SD 6.22) 10.18 (SD 6.22) GROUP 2 (OZiL/LONGITUDINAL) Mean US Time: 1 min 58 sec (SD 55.86 sec) 1 min 58 sec (SD 55.86 sec) Mean longitudinal US amp: 3.86 (SD 1.75) 3.86 (SD 1.75) Mean torsionel US amp: 3.92 (SD 1.41) 3.92 (SD 1.41)CDE: 9.89 (SD 7.00) 9.89 (SD 7.00) US time and phaco amplitudes were found lower in group 1 where as torsional amplitude was found higher in this group. CDE values were similar. (p1=0,014, p2=0,001, p3= 0,001, p4= 0,874)

13. OPERATION TIMES AND VOLUME OF BSS USED GROUP 1 (OZiL IP) Mean operation time: 15 min 56 sec (SD 4 min14sec) 15 min 56 sec (SD 4 min14sec) Mean volume of BSS used: 65.25 cc (SD 17.54) 65.25 cc (SD 17.54) GROUP 2 (OZiL/LONGITUDINAL) Mean operation time: 15 min 29 sec (SD 3 min 43sec) 15 min 29 sec (SD 3 min 43sec) Mean volume of BSS used: 84.55 cc (SD 28.35) 84.55 cc (SD 28.35) Mean operation times were similar: p=0,779 p=0,779 Statistically Significantly less amount of BSS used in group 1 p=0,017 p=0,017

14. POSTOPERATIVE CORNEAL EDEMA 0,500,53 P=0,823 (P>0,05) Postoperative mean Corneal edema of the groups were similar

15. CCT CHANGES 92,60 µ 96,70 µ Preop mean pachymeter readings: G 1= 536,65 µ G 2= 515,65 µ P=0,874 (P>0,05) post-op CCT changes of the groups were similar

16. ANTERIOR CHAMBER REACTIONS 0,56 0,50 P=0,625 (P>0,05) mean anterior chamber reactions of the groups were similar

17. Early UCVA and 3rd week BCVA of the groups (Snellen): G 1: 0,56 / 0,83 G 1: 0,56 / 0,83 G 2: 0,57 / 0,67 G 2: 0,57 / 0,67 P=0,881 (P>0,05) Mean post-op UCVA of the groups were similar Mean BCVA of G1 was found statistically insignificantly higher than G2 P=0,081 (P>0,05) There was not any complication affecting the visual outcome in both groups. POSTOPERATIVE VISUAL ACUITY

18. DISCUSSION Ozil torsional phaco is one of the important innovations in phacoemulsification technologies. Unlike the conventional longitudinal phaco, it produces a side-to- side motion of the phaco tip (1). Shearing effect is produced by the convertion of torsional movement to horizontal side to side motion by the aid of bent tips (2). 1. Liu Y, Zeng M, Liu X, Luo L, Yuan Z, Xia Y, Zeng Y. Torsional mode versus conventional ultrasound mode phacoemulsification; randomized comparative clinical study. J Cataract Refract Surg 2007;33:287–292 2. Davison JA. Cumulative tip travel and implied followability of longitudinal and torsional phacoemulsification. J Cataract Refract Surg 2008;34:986–990

19. DISCUSSION The clinnical advantages of torsional technology are (3,4); Efficient shearing effect results in less repulsion, Efficient shearing effect results in less repulsion, Decreased turbulance, Decreased turbulance, Less amount of heat production, Less amount of heat production, More stable anterior chamber. More stable anterior chamber. Increased followability. Increased followability. 3. Zeng M, Liu X, Liu Y, Xia Y, Luo L, Yuan Z, Zeng Y, Liu Y. Torsional ultrasound modality for hard nucleus phacoemulsification cataract extraction. Br J Ophthalmol 2008; 92:1092–1096 4. Hoffman RS, Fine IH, Packer M. New phacoemulsification technology. Curr Opin Ophthalmol 2005; 16:38–43

20. DISCUSSION Total occlusion of the tip should be avoided to have the the maximum efficiency of torsional phaco. IP (Intelligent Phaco) delivers a very small amount (short pulse) of longitudinal US just before the occlusion is complete, IP (Intelligent Phaco) delivers a very small amount (short pulse) of longitudinal US just before the occlusion is complete, With the IP upgrade; Occlusions decrease, Occlusions decrease, Diminished risk of clogging Diminished risk of clogging More stable anterior chamber, More stable anterior chamber, Shifts in th IOP decrease, Shifts in th IOP decrease, The eye is kept in a more natural state throughout the surgery The eye is kept in a more natural state throughout the surgery

21. DISCUSSION With the aid of IP upgrade the surgeries were performed safely and efficiently by using torsional phaco only. Following safety and efficacy measures were found similar between the Ozil IP and combined torsional/longitudinal groups: CDE, CDE, CCT changes CCT changes Visual acuities Visual acuities UST and volume of BSS used were significantly lower in IP group. No complications were observed in both groups

22. CONCLUSION Ozil IP torsional mode may provide more effective lens removal than combined torsional/longitudinal US mode with a lower UST and volume of BSS used.