1.8 mm Cataract Surgery: 1.8 mm Cataract Surgery: Clinical Results 6 Months after Clinical Results 6 Months after Coaxial and Biaxial MICS and Coaxial and Biaxial MICS and Implantation of a New Micro-Implantation of a New Micro-

incision IOL incision IOL

Rosa Braga-Mele, M. Ed, M.D., FRCS(S)Rosa Braga-Mele, M. Ed, M.D., FRCS(S)Associate Professor, University of Toronto, CanadaAssociate Professor, University of Toronto, Canada

Director of Cataract Unit and Surgical Teaching,Director of Cataract Unit and Surgical Teaching,Mount Sinai Hospital, TorontoMount Sinai Hospital, Toronto

Consultant for B&L, AMO and Alcon

MethodsMethodsA Pilot Study was conducted to evaluate the Stellaris A Pilot Study was conducted to evaluate the Stellaris Vision Enhancement System and a new microincisional Vision Enhancement System and a new microincisional IOL when used to perform phaco in a clinical setting by 1 IOL when used to perform phaco in a clinical setting by 1 surgeonsurgeonAt our center, we performed surgery with:At our center, we performed surgery with:– Biaxial MICSBiaxial MICS (1.4-1.6 mm incision) and MicroFlow needle (1.4-1.6 mm incision) and MicroFlow needle– Coaxial MICSCoaxial MICS (1.8 mm incision) with MICS 1.8 mm needle (1.8 mm incision) with MICS 1.8 mm needle

All patientsAll patients– +2 to +4 nuclear sclerotic cataracts+2 to +4 nuclear sclerotic cataracts– Insertion of the MI60 intraocular lens ( Insertion of the MI60 intraocular lens ( a microincisional IOL a microincisional IOL

delivered through a 1.8-1.9 mm incision)delivered through a 1.8-1.9 mm incision)

Both B-MICS and C-MICS surgeries Both B-MICS and C-MICS surgeries – Stellaris Advanced Flow Module in flow mode was usedStellaris Advanced Flow Module in flow mode was used

Intraoperative, Day 1 and 6 month data were analyzedIntraoperative, Day 1 and 6 month data were analyzed

Phaco Platform UsedPhaco Platform UsedChoice of Pump Systems; Choice of Pump Systems; Fluidic Options (Vacuum or Fluidic Options (Vacuum or Flow-based)Flow-based)6 Crystal Ultrasound hand 6 Crystal Ultrasound hand piecepieceCustom Power ModulationCustom Power ModulationMICS Platform Ready MICS Platform Ready Bimanual and Micro-Bimanual and Micro-coaxial techniques coaxial techniques – 1.4mm MICS1.4mm MICS– 1.8 and 2.2mm Coaxial 1.8 and 2.2mm Coaxial

MICSMICSWireless Dual Liner Foot Wireless Dual Liner Foot ControlControl

Stellaris Vision Enhancement Stellaris Vision Enhancement SystemSystem

Fluidic control & Power modulationsFluidic control & Power modulations

EQ Fluidics EQ Fluidics – Minimizes surge Minimizes surge

Highly accurate vacuum Highly accurate vacuum measurementsmeasurements

– Transducer sensitive to Transducer sensitive to extremely small extremely small changes in vacuumchanges in vacuum

– Non-contactNon-contact– Housed in low Housed in low

compliance materialcompliance material

Rapid response software Rapid response software controls pumpcontrols pump

– Avoid rapid influx of fluid Avoid rapid influx of fluid from anterior chamberfrom anterior chamber

Ultrasound ControlUltrasound Control– Advanced Custom Advanced Custom

Control Software Control Software – Extended hyper-Extended hyper-

pulse and micro-pulse and micro-burst modesburst modes

– Pulse shapingPulse shapingincreases followabilityincreases followability

Microincision IOL (Akreos MI60)Microincision IOL (Akreos MI60)

Material is flexible, Material is flexible, deformable, resists deformable, resists tearingtearing

Suitable for injection Suitable for injection through sub-2 mm through sub-2 mm incisionincision

Minimize PCO with 4 Minimize PCO with 4 angulated haptics (10°) angulated haptics (10°) and a continuous 360° and a continuous 360° barrierbarrier

Stable in the bag through Stable in the bag through suitable haptic design suitable haptic design

Settings Used on Stellaris AFMSettings Used on Stellaris AFM

Sculpting Sculpting Segment RemovalSegment Removal60 mmHg Vac 60 mmHg Vac 475 mmHg Vac 475 mmHg Vac

30 cc/min flow 30 cc/min flow 35-45 cc/min 35-45 cc/min Dual Linear Flow Dual Linear Flow

30% power 30% power continuous continuous

20% power 20% power 6 ms on/ 12ms off6 ms on/ 12ms off

75 cm BH 75 cm BH 120 cm BH120 cm BH

For B-MICS BH raised by 10 cm over above settings

BMICS BMICS MicroFlow MicroFlow

Needle (N= Needle (N= 2020))

Needle for 1.8 Needle for 1.8 CMICS (N=CMICS (N=2020))

Average phaco Average phaco powerpower 14%14% 18.5%18.5%

Absolute phaco Absolute phaco timetime 32.6 sec32.6 sec 17.7 sec17.7 sec

Effective phaco Effective phaco timetime 4.5 sec4.5 sec 3.3 sec3.3 sec

Intraoperative ParametersAdvanced Flow Module – Flow Mode UsedAdvanced Flow Module – Flow Mode Used (N= (N=4040))

IntraoperativeIntraoperative

At end of phaco wound size was re-measuredAt end of phaco wound size was re-measured– BMICS 1.5 mm (enlarged to 1.8 for IOL)BMICS 1.5 mm (enlarged to 1.8 for IOL)– CMICS 1.8 mmCMICS 1.8 mm

MI60 IOL was inserted through 1.8 mm incision MI60 IOL was inserted through 1.8 mm incision with minimal or no difficultywith minimal or no difficulty– Gentle insertion, no tissue damageGentle insertion, no tissue damage– Easily unfolds into capsular bagEasily unfolds into capsular bag– Centres immediatelyCentres immediately– End of insertion: wound re-measured: 1.9mm in all End of insertion: wound re-measured: 1.9mm in all

casescases

1.8 mm C-MICs with MI60 IOL insertion1.8 mm C-MICs with MI60 IOL insertion

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Day 1 PostoperativelyDay 1 Postoperatively

Biaxial MICSBiaxial MICS(1.4-1.6 mm incision)(1.4-1.6 mm incision)

N=20N=20

Coaxial MICS Coaxial MICS (1.8 mm Incision)(1.8 mm Incision)

N=20N=20

Corneal Corneal ClarityClarity ClearClear ClearClear

BCVABCVA All eyes 20/25 All eyes 20/25 All eyes 20/20All eyes 20/20

• IOL well-centeredIOL well-centered• Subjectively, patients happy with no complaintsSubjectively, patients happy with no complaints

Month 6 PostoperativelyMonth 6 PostoperativelyBiaxial MICSBiaxial MICS

(1.4-1.6 mm incision)(1.4-1.6 mm incision)

N=20N=20

Coaxial MICS Coaxial MICS (1.8 mm (1.8 mm Incision)Incision)

N=20N=20

Corneal Corneal ClarityClarity ClearClear ClearClear

BCVABCVA All eyes 20/20 All eyes 20/20 All eyes 20/20All eyes 20/20

• No induced astigmatismNo induced astigmatism• Good contrast sensitivityGood contrast sensitivity• IOL well-centered IOL well-centered • Subjectively, patients happy with no complaints (no Subjectively, patients happy with no complaints (no edge glare, halos)edge glare, halos)

SummarySummary

AFM Flow moduleAFM Flow module– Enhances nuclear removal while minimizing required phaco Enhances nuclear removal while minimizing required phaco

energy and good chamber stabilityenergy and good chamber stability

Similar phaco time and power utilization for both BMICS Similar phaco time and power utilization for both BMICS AND CMICS AND CMICS Slightly better fluidic control and chamber stability using Slightly better fluidic control and chamber stability using the 1.8 mm CMICS setup over BMICSthe 1.8 mm CMICS setup over BMICSLearning curve shortLearning curve short– Specifically for CMICS procedureSpecifically for CMICS procedure

Good postoperative outcomes with minimal or no Good postoperative outcomes with minimal or no induced astigmatism and good IOL centration with good induced astigmatism and good IOL centration with good visual outcomes for patients (using MI60 IOL and 6 mos visual outcomes for patients (using MI60 IOL and 6 mos f/u)f/u)