Eyeworld Supplements

2 EW Boston 2014 Sunday, April 27, 2014 2 Active Fluidics in a non-routine cataract case by Richard Mackool, MD Richard Mackool, MD " The advantages of the Centurion Vision System and AutoSert IOL Injector are indeed complimentary. Together they have increased our ability to perform atraumatic and precise cataract implant surgery with greater refractive accuracy through a smaller cataract incision. " A ctive Fluidics, by con- stantly monitoring and adapting to changes in target IOP, can benefit patients and surgeons during uneventful as well as unusual procedures. As an example, I was performing cataract surgery under topical anes- thesia on the highly nearsighted eye (axial length: 27 mm) of a 55- year-old ophthalmologist. The IOP setting on the Centurion Vision System (Alcon, Fort Worth, Texas) was 80 mmHg, which is equivalent to an infusion bottle height of 110 cm. As I inserted the phaco tip into the eye, he reported severe discomfort. In my experience, this very unusual problem occurs only in highly nearsighted eyes and is almost certainly the result of stretching of the thin sclera and adjacent choroid during periods of IOP elevation. Stretching choroidal nerves is not only extremely uncom- fortable, it is downright painful. In the past, options to deal with this situation have included the following: • Performing a peribulbar or retrobulbar block. This solves the problem but of course exposes the patient to the potential complications of such injections. This is why many surgeons prefer topical anesthesia. • Administering a large amount of intravenous sedation to render the patient unconscious or nearly so. This carries some systemic risks, as well as the risk of ocular com- plications associated with poor patient cooperation. As we are all aware, marginally conscious patients can do things that jeopardize the outcome of the procedure. • Lowering the infusion bottle height to about 60 cm to reduce IOP to about 40 mmHg in foot pedal position 1. The good news with this option is that the patient will not have pain. The very bad news is that in order to avoid severe chamber instability, fluidic parameters would have to be so low that the duration of the procedure could be measured using a calendar. The prolonged procedure results in a large IOP at or near the preset target IOP level). There is no other system on the market today that manages fluidics like the Centurion Vision System Active Fluidics. This patient had experienced pain at an IOP setting of 80 mmHg, so I reduced the target IOP to 55 mmHg. He experienced only mild and transient discomfort as the instrument was inserted, and the phacoemulsification procedure was safely completed using an aspiration flow rate of 25 cc/min and vacuum level of 400 mmHg during which time the target IOP would have been approximately 40 mmHg. The fluidic advantages of the Centurion Vision System also helped to increase postoperative refractive accuracy. Because the instrument maintains a target IOP and chamber stability so well, even when the smallest of phaco incisions are em- ployed, there is simply no advantage to using a larger infusion sleeve that typically requires an incision of 2.6 to 3.0 mm. All Centurion Vision System surgeons can therefore im- mediately reduce their incision size to 2.4 mm or less, thereby decreas- ing surgically induced astigmatism as well as the risk of postoperative incision leakage, suturing of the in- cision, and even endophthalmitis. There is virtually no learning curve associated with this switch to a smaller incision. When inserting the IOL through these smaller incisions, the foot pedal control of the Intrepid AutoSert IOL Injector (Alcon) offers a great advantage because it frees the surgeon's non- dominant hand so that it can be used to both position the eye and the IOL as the lens enters the eye and capsular bag. It also permits precise control of the rate at which the IOL is delivered. The advantages of the Centurion Vision System and AutoSert IOL Injector are indeed complimentary. Together they have increased our ability to perform atraumatic and precise cataract implant surgery with greater refractive accuracy through a smaller cataract incision. Dr. Mackool is in private practice in Astoria, N.Y. He can be contacted at Mackooleye@aol.com. Centurion Vision System Please refer to pages 6 and 7 for important product information about the Alcon products described in this supplement. amount of fluid passing through the eye, traumatizing the iris and cornea. The Centurion Vision System changes all of this. It permits the surgeon to set a target IOP that is comfortable for each patient and to maintain it even when using fluidic parameters that will enable the cataract to be removed efficiently. Previously, we used an infusion bottle that remained at one height throughout the procedure. It would have been ideal, but physically impossible, to have someone in the OR rapidly elevating and lowering the bottle depending upon the rate at which fluid was leaving the eye in order to maintain a reasonably consistent IOP. Remarkably, this is essentially what the Centurion Vision System does (i.e., it monitors the pressure in the infusion and aspiration lines and instantaneously changes the amount of flow into the eye in order to maintain the targeted Click to view videos Centurion Vision System Active Fluidics Centurion Vision System Fluid Management System

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