Cataract Surgery Innovations
Pearls for AquaLase use

Techniques for its use have evolved

A growing body of evidence suggests that surgeons have evolved their techniques with AquaLase (Alcon, Fort Worth, Texas) and found new uses for it, making it a more relevant tool in the ophthalmic armamentarium than ever.
Combined with a prechop or phaco-chop technique, some have found AquaLase to be effective on denser cataracts. Some also have found it to be safer, such as causing less edema, than ultrasound. And they have found speed to be on par with ultrasound in many cases.
Less edema
In a recent study, Thaddeus Demong, M.D., Demong Associate Eyecentre, Canada, compared AquaLase with Infiniti ultrasound (Alcon). The study was presented at the XXIII Congress of the ESCRS in Lisbon, Portugal.
Dr. Demong compared 50 patients (100 eyes) using an Akahoshi pre-chop technique followed by AquaLase or ultrasound. Cataract grades 1 through 3 were studied. When possible, surgeons performed a bilateral approach with the first eye selected randomly.
The effective phacoemulsification time for ultrasound was 1.35 seconds, while the AquaLase time was 0.65 seconds. Aspiration time was 4.15 minutes for ultrasound and 3.67 minutes for AquaLase. Peak vacuum was 596.13 mm Hg for ultrasound and 537.0 mm Hg for AquaLase. These results “are comparable,” Dr. Demong found.
However, he said, in the ultrasound group, 22.9% had mild epithelial edema, while just 6.25% of the AquaLase group did. There was no ruptured posterior capsule, vitreous loss, or hemorrhage in either group, he found.
“The Alcon Infiniti ultrasound phacoemulsification and the AquaLase are both safe and effective,” Dr. Demong concluded. “However the AquaLase caused significantly less edema and achieved greater change in refractive cylinder when used in surgery for removal of moderate cataracts grades 1 and 2 up to grade 3.” The refractive cylinder change was 19.2% with ultrasound and 48% with AquaLase.

Attacking different densities

Child with lens coloboma and
cataract.


Newborn child with nuclear catract
dense in the center.


Posterior cataract with PFV.




Dense congenital cataract (left)
and an incomplete congential
cataract.

Source: Charlotta Zetterstrom, M.D.,
Ph.D.

Meanwhile, Jacek Szendzielorz, M.D., medical director, Lens-Med, Poland, found that phaco chop performed in conjunction with AquaLase could allow a surgeon to emulsify higher-density nuclei.
In his study, also presented at the ESCRS meeting, patients were divided into two groups, which he labeled A and B. Group A underwent conventional ultrasound. Group B underwent AquaLase.
“Using phaco-chop technique, it is technically possible to operate on patients with a 3 and even 4 cataract density stage using AquaLase,” Dr. Szendzielorz reported.
However, he said, he noticed a significant increase in operation time for those denser nuclei compared with ultrasound.
The time to perform operations on nuclei of 1, 2, and 2+ densities were very similar, however, Dr. Szendzielorz found.
Another benefit of AquaLase may be that it induces less astigmatism, according to Dr. Szendzielorz’s results.
The average surgically induced astigmatism varied from 0.75 D to 2.5 D for group A, but was only 0.25 D to 0.75 D for group B, results showed. Follow-up for all cases varied from three to 12 months.

An alternative use

Even if a surgeon doesn’t like to use AquaLase for routine cataract surgeries, it could still be a valuable tool in certain complicated situations.
Rolando Toyos, M.D., medical director, Toyos Clinic, Jackson, Tenn., described a new technique called “AquaSave,” also presented at the ESCRS meeting.
From time to time, posterior capsule rupture can occur during cataract surgery. When this happens, Dr. Toyos said, it’s important to maintain the integrity of the posterior capsule remnants while removing the cataract remainder.
Dr. Toyos suggested that the AquaSave technique can do this effectively after performing the technique in his study.
He analyzed 10 Miyake eyes that had partial cataract removal with phacoemulsification until they deliberately underwent posterior capsular rupture.
The posterior capsular IOLs were then placed in the bags and sulcus. After IOL implantation, the remaining lens material was removed using warm balanced salt solution pulses and the AquaLase tip. Dr. Toyos monitored the loss of vitreous, the capsular bag integrity, and the IOLs with the Miyake technique.
“Following posterior capsule rupture and subsequent implantation of posterior capsular intraocular lens, further damage to posterior capsules was not observed,” Dr. Toyos noted.
“We did not observe any damage to implanted intraocular lenses or increased trauma to posterior capsules following removal of the remaining lens material with warm balanced salt solution and AquaLase tip. We observed minimal vitreous loss and a decreased occurrence of vitrectomy,” he said.
Dr. Toyos concluded that this AquaSave technique was a successful way to maintain the ruptured posterior capsule as well as vitreous integrity.
Despite the touted advances of AquaLase, Richard Hoffman, M.D., clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, remains dubious.
“It’s not efficient for denser lenses, including 3+ and 4+ nuclear sclerotic cataracts,” Dr. Hoffman said. “The main advantage is theoretically you are less likely to rupture the posterior capsule because you’re moving fluid rather than using mechanical energy, but usually that happens because of aspiration of the posterior capsule, not because of phaco energy.”
When the AquaLase technology was developed years ago, it was promising, but ultrasound has advanced to the point where it is extremely safe and effective, Dr. Hoffman said.
There is still one potential advantage for AquaLase that remains, however: The ability to remove lens epithelial cells from the capsular bag, Dr. Hoffman said.
“If you remove those, then you may significantly decrease the rate of PCO [posterior capsule opacification],” he said. Furthermore, he said, removing lens epithelial cells should result in less capsule fibrosis which may improve the functioning of accommodative IOLs and injectable polymer IOLs that may be available in the future.

Editors’ note: Dr. Demong received funding from Alcon for his study. Dr. Szendzielorz reported no financial interests related to his study. Dr. Toyos is a speaker for Alcon. Dr. Hoffman occasionally acted as a speaker for Advanced Medical Optics (Santa Ana, Calif.) in the past.

Contact Information
Demong: 403-254-2408, director@demong.com
Hoffman: 541-687-2110, rshoffman@finemd.com
Szendzielorz: +48 32 329 80 88, okulista@lensmed.pl
Toyos: 731-660-3937, mreynolds@toyosclinic.com