Purpose To compare clinical results of biaxial small-incision torsional phacoemulsification and biaxial small-incision longitudinal phacoemulsification. Setting Department of Ophthalmology, School of Medicine, Namik Kemal University, Tekirdag, Turkey. Design Randomized controlled clinical trial. Methods Eyes with high-density nuclear cataract were assigned to have biaxial longitudinal (microburst mode) or biaxial torsional phacoemulsification. The main outcomes included corrected distance visual acuity (CDVA), central corneal thickness (CCT), central endothelial cell density (ECD), total ultrasound time (UST), cumulative dissipated energy (CDE), percentage total equivalent power in position 3, and balanced salt solution volume. Postoperative follow-up was at 1 day, 1 week, and 1 and 3 months. Results Each group comprised 35 patients (35 eyes). Three months postoperatively, the mean CDVA for each group was 0.02 logMAR and the mean CCT returned to the preoperative level (P=.589 and P=.554, respectively). During the postoperative follow-up, the percentage of mean endothelial cell loss in both groups was between 35.4% and 39.1%; there was no statistically significant difference between the groups (P>.05). The mean CDE, UST, percentage total equivalent power in position 3, and balanced salt solution volume values were similar in the 2 groups (P>.05). Conclusion The risk for high endothelial cell loss should be considered when the phacoemulsification of high-density nuclear cataracts is performed using either method. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Endothelial cell loss: Biaxial small-incision torsional phacoemulsification versus biaxial small-incision longitudinal phacoemulsification

AIM To compare the intraoperative performance and postoperative outcome after microcoaxial torsional phacoemulsification using either a Kelman or balanced phaco tip. METHODS Cataracts were treated using 2.2 mm microcoaxial torsional phacoemulsification using either a 45-degree mini-flared Kelman(®) or a 45-degree Intrepid(®) Balanced phaco tip. Intraoperative measurements included total ultrasound (US) time, cumulative dissipated energy (CDE), torsional US time, and balanced salt solution (BSS) use. The central endothelial cell density (ECD) and central corneal thickness (CCT) were evaluated preoperatively and postoperatively 1, 7, and 30d after surgery using noncontact specular microscopy. RESULTS The 116 enrolled eyes (116 patients) were divided equally between the Kelman and balanced tip groups. Intraoperative measurements showed significantly less total US time, torsional US time, CDE, and BSS use in the balanced group than in Kelman group (P<0.05). The total US time, torsional US time, CDE, and BSS use were 17.45±14.53s, 16.63±13.97s, 6.38±5.26, and 48.21±17.21 mL in the Kelman group and 11.39 ± 9.60s, 10.90 ± 9.25s, 4.04 ± 3.42, and 41.36 ± 12.70 mL in the balanced group, respectively. CONCLUSION Torsional phacoemulsification performed with a balanced tip provided more effective lens removal with less total US time, torsional time, CDE, and BSS use, as well as similar changes in ECD with a Kelman tip in all cataract grades. This special designed phaco tip for torsional phacoemulsification provides an alternative phaco tip for many surgeons' preference with straight phaco tip.

Comparison of 45-degree Kelman and 45-degree balanced phaco tip designs in torsional microcoaxial phacoemulsification

Purpose To compare the safety and efficacy of Ozil Intelligent Phaco torsional microcoaxial phacoemulsification surgeries performed using 30-degree and 45-degree aperture angled tips. Setting Maltepe University School of Medicine Department of Ophthalmology, Istanbul, Turkey. Design Comparative case series. Methods Eyes were assigned to 2.2 mm microcoaxial phacoemulsification using the torsional mode with a 45-degree (Group 1) or 30-degree (Group 2) aperture angled tip. A quick-chop surgical technique was used. The primary outcome measures were ultrasound time (UST), cumulative dissipated energy (CDE), longitudinal and torsional ultrasound (US) amplitudes, mean surgical time, mean balanced salt solution volume used, and mean central corneal thickness (CCT) changes. Results The mean UST, CDE, and longitudinal and torsional US amplitudes were 58.21 seconds ± 33.81 (SD), 7.74 ± 6.23, 0.45 ± 0.30, and 26.30 ± 12.60 in Group 1 and 63.83 ± 23.42 seconds, 12.36 ± 6.75, 0.23 ± 0.26, and 44.65 ± 14.38 in Group 2, respectively. The mean CDE and torsional amplitudes were significantly lower in Group 1 (P=.002 and P=.001, respectively). The mean balanced salt solution volume was 73.30 ± 19.87 cc in Group 1 and 74.30 ± 19.44 cc in Group 2 (P=.821). The mean CCT change was 52.40 ± 38.08 μm and 99.35 ± 47.14 μm, respectively (P Conclusion Torsional phacoemulsification performed with a 45-degree aperture angled tip provided more effective lens removal with a lower CDE and less CCT change than a 30-degree aperture angled tip. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of torsional microcoaxial phacoemulsification using tips with 30-degree and 45-degree aperture angles

Purpose To assess the incidence and associations of lens–iris diaphragm retropulsion syndrome (LIDRS) during phacoemulsification in patients who have had vitrectomy. Setting Sunderland Eye Infirmary, Sunderland, United Kingdom. Design Case series. Methods The LIDRS was categorized into none, mild, and moderate/severe. Unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of increased LIDRS severity were estimated. Results Of the 75 eyes (75 patients) included, 35 (46.7%) had no LIDRS and 40 (53.3%) had LIDRS. The odds of increased LIDRS severity decreased significantly with age (OR = 0.92; 95% CI, 0.88-0.97) ( P =.001) and increased with increasing axial length (AL) (OR = 3.26; 95% CI, 2.04-5.20) ( P P =.002). The odds were greater in extensive vitrectomy than in limited vitrectomy (OR = 4.40; 95% CI, 1.64-11.84) ( P =.003) and in men than in women (OR = 3.39; 95% CI, 1.40-8.23) ( P =.007). The adjusted odds of increased LIDRS severity were significantly greater in extensive vitrectomy than in limited vitrectomy (adjusted OR=4.42; 95% CI, 1.19-16.45) ( P =.027) and with increasing AL (adjusted OR=3.05; 95% CI, 1.86-5.01) ( P Conclusions Lens–iris diaphragm retropulsion syndrome occurred frequently in eyes with previous vitrectomy. Several identifiable factors had a significant association with the occurrence of LIDRS, and these could be used to help in the preoperative counseling of patients and in surgical planning. Financial Disclosure Dr. Steel has attended advisory board meetings for Alcon Laboratories, Inc., Novartis Corp., and Thrombogenics NV. No other author has a financial or proprietary interest in any material or method mentioned.

Lens-iris diaphragm retropulsion syndrome during phacoemulsification in vitrectomized eyes

Purpose To compare the safety and efficacy of Ozil Intelligent Phaco torsional microcoaxial phacoemulsification surgeries performed with 12-degree and 22-degree bent tips using the Infiniti Vision System. Setting Maltepe University School of Medicine Department of Ophthalmology, Istanbul, Turkey. Design Comparative case series. Methods Eyes were assigned to 2.2 mm microcoaxial phacoemulsification using the torsional mode with a 22-degree bent tip (Group 1) or a 12-degree bent tip (Group 2). The primary outcome measures were ultrasound time (UST), cumulative dissipated energy (CDE), longitudinal and torsional ultrasound (US) amplitudes, mean surgical time, mean volume of balanced salt solution used, and surgical complications. Results Both groups included 45 eyes. The mean UST, CDE, longitudinal US amplitude, and torsional US amplitude were 65 seconds ± 27.23 (SD), 11.53 ± 6.99, 0.22 ± 0.26, and 42.86 ± 15.64, respectively, in Group 1 and 84 ± 45.04 seconds, 16.68 ± 10.66, 0.48 ± 0.68, and 46.27 ± 14.74, respectively, in Group 2. The mean UST, CDE, and longitudinal amplitudes were significantly lower in Group 1 ( P =.003, P =.008, and P =.022, respectively). The mean volume of balanced salt solution was 73.33 ± 28.58 cc in Group 1 and 82.08 ± 26.21 cc in Group 2 ( P =.134). Conclusion Torsional phacoemulsification performed with 22-degree bent tips provided more effective lens removal than 12-degree bent tips, with a lower UST and CDE. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Outcomes of torsional microcoaxial phacoemulsification performed by 12-degree and 22-degree bent tips.

Purpose To evaluate the efficiency profile of new torsional phacoemulsification software. Setting Eye Institute of Utah, Salt Lake City, Utah, USA. Design Comparative case series. Methods Routine cataract surgeries were performed using standard torsional (Ozil) and new torsional (Ozil IP) software. The new software uses occasional pulses of longitudinal energy that are operator specified and system controlled to manage potential occlusion. The new software was compared with the previous standard software, which did not include this option. The video monitor system was recorded in high definition. Measurement of cumulative dissipated energy, balanced salt solution use, and amount of time spent in occlusion were measured in a frame-by-frame review of the recorded videos. Data were categorized for analysis by software group and cataract grade (1 to 4). Results The study comprised 59 eyes that had cataract removal using the new torsional software and 59 eyes using the standard torsional software. Cumulative dissipated energy was not statistically significantly different between the 2 groups. Balanced salt solution use, time spent in occlusion, and the mean longest continuous occlusion were significantly lower with the new torsional software; these differences were greater as the cataract grade increased. Conclusions The new torsional software significantly decreased occlusion time and balanced salt solution use over standard torsional software, particularly with denser cataracts. The net result was a relatively better safety cataract surgery profile. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Length and frequency of intraoperative occlusive events with new torsional phacoemulsification software.

Purpose: To compare the frequency and types of flap complications when a femtosecond laser versus a microkeratome is used in flap creation for laser in situ keratomileusis (LASIK)Methods:  Retrospective review of private and published results of intraoperative and postoperative complications seen with mechanical microkeratomes and the femtosecond laser The data from 13,721 consecutive mechanical microkeratome created flaps and 10,348 consecutive femtosecond laser created flaps for LASIK performed by one surgeon (KS) were analyzed for this studyResults:  A lower rate of intraoperative complications (incomplete flap, buttonhole, free cap, thin/irregular flap) was seen in the femtosecond created flaps (0019%) compared to the microkeratome created flaps in this study (0095%, p<0001) and large published studies (080%, p<0001)  Less postoperative complications (epithelial ingrowth, keratectasia) were also seen in the femtosecond group (003%) compared to the microkeratome group (014%, p=001) There were several complications seen that were unique to the femtosecond laser, including transient light sensitivity, anterior chamber bubbles and vertical gas breakthrough Conclusions: Intraoperative and postoperative flap complications were significantly higher with mechanical microkeratomes compared to the femtosecond laser  Femtosecond laser flap creation resulted in some complications that were unique to this modalityKey Words: LASIK, Flap Complications, Microkeratome, Intralase, Femtosecond Laser

David J Felsted

Papers

Length and frequency of intraoperative occlusive events with new torsional phacoemulsification software.

Laser in situ keratomileusis flap complications and complication rates using mechanical microkeratomes versus femtosecond laser: Retrospective review