IS PHACO DEAD?

Ophthalmic surgeons caught in the throes of infatuation with femtosecond laser-assisted cataract surgery, shouldn’t forget the virtues of their long-term relationship with phaco, cautions Gerd Auffarth MD, PhD, chairman of the Department of Ophthalmology, Heidelberg University.

Asking "is phaco dead?", he told the World Ophthalmology Congress (WOC) in Tokyo the answer had to be an emphatic "no".

Dr Auffarth did not deny that the femtosecond laser brings a number of important potential improvements to cataract surgery, from improving on the capsulorhexis to fragmenting the lens. However, he noted that phacoemulsification has evolved considerably and will continue to do so.

“With phacoemulsification we have 40 years of technological development. You know what you are getting. You know how to handle it. We have evidence-based outcomes research of cost effectiveness. Indeed it is still the gold standard of cataract surgery for the majority of cases. I expect that as we combine the best features of femto and phaco there will be no limit to what we can do. This is just the beginning,” said Dr Auffarth, who is also director of the International Vision Correction Research Centre and the David J Apple International Laboratory for Ocular Pathology.

Following his legendary epiphany in the dentist’s chair, Charles Kelman first introduced the concept of phacoemulsification in 1967. Since that time there has been a steady progression of technical developments. Most notably, the latest generation of phacoemulsification machines all offer advanced systems allowing many ultrasound power options, control of fluidics and chamber stability.

Microburst technology

One of the most important developments has been the advent of more refined ways to attack the lens nucleus. Microburst technology allows the surgeon to apply energy in different ways, while reducing the temperature. The incidence of corneal burns has been markedly reduced by this technology, he explained. Another key development in the evolution of phacoemulsification has been changing how the phaco tip moves. For 30 years, there was only one choice, longitudinal motion. Now phaco systems provide several options including torsional and transversal motion.

“This has led to further reductions in the amount of phaco energy required for cataract surgery. Ten years ago we were counting phaco time in minutes, now we are counting in seconds or even microseconds,” he said.

Pump systems also continue to evolve. Current phaco systems allow the surgeon to move between one, two or three pump systems on the fly. “Now the machine is thinking for you. It is keeping the energy and temperature stable, and keeping a certain pressure in the eye. Previous problems like surge are very rare these days. This gives you the opportunity to extend the option of cataract surgery to more patients, who might have not been good candidates in the past.”

Gerd Auffarth: ga@uni-hd.de