1. 1.8 mm Cataract Surgery: Clinical Results 6 Months after Coaxial and Biaxial MICS and Implantation of a New Micro- incision IOL Rosa Braga-Mele, M. Ed, M.D., FRCS(S) Associate Professor, University of Toronto, Canada Director of Cataract Unit and Surgical Teaching, Mount Sinai Hospital, Toronto Consultant for B&L, AMO and Alcon

2. Methods A Pilot Study was conducted to evaluate the Stellaris Vision Enhancement System and a new microincisional IOL when used to perform phaco in a clinical setting by 1 surgeon At our center, we performed surgery with: –Biaxial MICS (1.4-1.6 mm incision) and MicroFlow needle –Coaxial MICS (1.8 mm incision) with MICS 1.8 mm needle All patients –+2 to +4 nuclear sclerotic cataracts –Insertion of the MI60 intraocular lens ( a microincisional IOL delivered through a 1.8-1.9 mm incision) Both B-MICS and C-MICS surgeries –Stellaris Advanced Flow Module in flow mode was used Intraoperative, Day 1 and 6 month data were analyzed

3. Phaco Platform Used Choice of Pump Systems; Fluidic Options (Vacuum or Flow-based) 6 Crystal Ultrasound hand piece Custom Power Modulation MICS Platform Ready Bimanual and Micro- coaxial techniques –1.4mm MICS –1.8 and 2.2mm Coaxial MICS Wireless Dual Liner Foot Control Stellaris Vision Enhancement System

4. Fluidic control & Power modulations EQ Fluidics –Minimizes surge Highly accurate vacuum measurements –Transducer sensitive to extremely small changes in vacuum –Non-contact –Housed in low compliance material Rapid response software controls pump –Avoid rapid influx of fluid from anterior chamber Ultrasound Control –Advanced Custom Control Software –Extended hyper- pulse and micro- burst modes –Pulse shaping increases followability

5. Microincision IOL (Akreos MI60) Material is flexible, deformable, resists tearing Suitable for injection through sub-2 mm incision Minimize PCO with 4 angulated haptics (10°) and a continuous 360° barrier Stable in the bag through suitable haptic design

6. Settings Used on Stellaris AFM Sculpting Segment Removal 60 mmHg Vac 475 mmHg Vac 30 cc/min flow 35-45 cc/min Dual Linear Flow 30% power continuous 20% power 6 ms on/ 12ms off 75 cm BH 120 cm BH For B-MICS BH raised by 10 cm over above settings

7. BMICS MicroFlow Needle (N= 20) Needle for 1.8 CMICS (N=20) Needle for 1.8 CMICS (N=20) Average phaco power 14%18.5% Absolute phaco time 32.6 sec 17.7 sec Effective phaco time 4.5 sec 3.3 sec Intraoperative Parameters Advanced Flow Module – Flow Mode Used (N=40)

8. Intraoperative At end of phaco wound size was re-measured –BMICS 1.5 mm (enlarged to 1.8 for IOL) –CMICS 1.8 mm MI60 IOL was inserted through 1.8 mm incision with minimal or no difficulty –Gentle insertion, no tissue damage –Easily unfolds into capsular bag –Centres immediately –End of insertion: wound re-measured: 1.9mm in all cases

9. 1.8 mm C-MICs with MI60 IOL insertion PLEASE CLICK ON VIDEO FILE IF NOT PLAYING HERE. THANK YOU.

10. Day 1 Postoperatively Biaxial MICS (1.4-1.6 mm incision) N=20 Coaxial MICS (1.8 mm Incision) N=20 Corneal Clarity ClearClear BCVA All eyes 20/25 All eyes 20/20 IOL well-centered IOL well-centered Subjectively, patients happy with no complaints Subjectively, patients happy with no complaints

11. Month 6 Postoperatively Biaxial MICS (1.4-1.6 mm incision) N=20 Coaxial MICS (1.8 mm Incision) N=20 Corneal Clarity ClearClear BCVA All eyes 20/20 No induced astigmatism No induced astigmatism Good contrast sensitivity Good contrast sensitivity IOL well-centered IOL well-centered Subjectively, patients happy with no complaints (no edge glare, halos) Subjectively, patients happy with no complaints (no edge glare, halos)

12. Summary AFM Flow module –Enhances nuclear removal while minimizing required phaco energy and good chamber stability Similar phaco time and power utilization for both BMICS AND CMICS Slightly better fluidic control and chamber stability using the 1.8 mm CMICS setup over BMICS Learning curve short –Specifically for CMICS procedure Good postoperative outcomes with minimal or no induced astigmatism and good IOL centration with good visual outcomes for patients (using MI60 IOL and 6 mos f/u)