5.3.3 MICS with Different Platforms: Stellaris Vision Enhancement System

Fig. 5.34 BMICS with Signature

Take Home Pearls

ßAppropriate choice of incision size, tip size, ultrasound and fluidics settings is essential for

successful MICS with either the Infiniti or Signature phaco machines.

ßWound-assisted lens insertion with minimal enlargement with BMICS and none with

CMICS completes the procedure with both these machines.

5.3.3MICS with Different Platforms: Stellaris Vision Enhancement System

Mark Packer, I. Howard Fine,

and Richard S. Hoffman

Core Messages

ßInnovative design concepts incorporated into the Stellaris Vision Enhancement System make

it a superlative choice for MICS. These concepts include monitoring and maintenance of fluidic parameters, millisecond level surgeon control of ultrasound power and ergonomic comfort and adaptability for any surgical technique.

ßThe Stellaris Vision Enhancement System is safe and effective for BMICS and CMICS.

ßThe advantages of BMICS include enhanced surgical flexibility and control made possible

by separation of inflow and outflow.

ßThe CMICS solution enables the incision to be decreased to 1.8 mm without any change in the

current coaxial phaco technique.

5.3.3.1 Innovations in Phacoemulsification

The Stellaris Vision Enhancement System (Bausch & Lomb, San Dimas, CA) represents revolutionary progress in phacoemulsification technology (Fig. 5.36). Building on the success of the Millennium, which has offered both Venturi and peristaltic pumps with dual linear foot pedal control, the Stellaris incorporates multiple advances in design. Innovative Stellaris System technology includes the Advanced Flow Module that allows intraoperative toggling between flow and vacuum modes, and also accurately monitors and maintains targeted vacuum levels and intraoperative aspiration rate; the StableChamber Pack, containing small diameter

M. Packer ( )

Oregon Health & Science University, Drs. Fine, Hoffman and Packer, 1550 Oak Street, Eugene, OR 97401, USA

e-mail: mpacker@finemd.com

Fig. 5.35 The Stellaris vision enhancement system presents a sleek and flexible design

tubing that increases resistance for high vacuum and steady low flow with internal mesh designed to capture material and prevent clogging; CustomControl Software II that permits millisecond range modulation ultrasound control and variable duty cycle application of 28.5 kHz ultrasound for optimized cavitation and rapid emulsification with minimal thermal loading; Bluetooth wireless dual linear foot pedal for instantaneous surgeon control of aspiration and ultrasound; and a light and agile six-crystal configuration handpiece for enhanced ergonomics and balance. These advances in technology provide real advantages for Micro Incision Cataract Surgery, both biaxial and coaxial.

The Stellaris provides solid chamber stability with EQ (equalizing) Fluidics Management Technology in vacuum or flow modes through equalization of aspiration and irrigation. This innovative system allows surgeons to equalize aspiration and irrigation for solid chamber stability in flow and vacuum modes when

Fig. 5.36 The StableChamber pack includes a mesh filter and a flow restriction which prevents surge

using advanced MICS techniques. Sensing technology accurately maintains preset vacuum and aspiration flow throughout the procedure for smooth, safe, and efficient material removal. The unique EQ technology monitors vacuum levels in flow mode, and precisely measures and controls vacuum when in vacuum mode for predictable performance. EQ-sensing technology monitors and adjusts flow to pre-emptively reduce the effects of postocclusion surge. Once occlusion breaks, Stellaris regulates the Flow in the aspiration line stabilizing the anterior chamber for increased control and safety.

In addition, the StableChamber pack controls flow for added chamber stability in high vacuum settings preferred for C and BMICS (Fig. 5.36). The pack essentially consists of small diameter tubing integrated into the aspiration line that increases resistance for high vacuum and steady low flow. Internal mesh designed to capture material and prevent clogging minimizes variability in steady state flow. The flow restriction in the StableChamber pack, together with the EQ-sensing technology that monitors and maintains stable pressure for predictable surgery, provides exceptional post occlusion surge responsiveness for rapid return to equalized state for solid chamber stability.

The Stellaris also features unique integration of lat- est-generation centrifugal pump and valve technology for responsiveness and aspiration efficiency that exceeds the performance of earlier Venturi systems. Advanced sensing technology accurately monitors and maintains targeted vacuum levels and intraoperative aspiration rate. These features safely increase the vacuum limit from 550 to 600 mmHg. Also, the Stellaris eliminates the need for an external gas supply by using an all-electric design. Additional safety features in the fluidics include real-time display of cassette fluid

volume via an optical sensor, increased capacity 300 ml cassette and SureLock locking irrigation connectors.

On the power delivery side, the unique six-crystal handpiece is ergonomically designed for excellent balance, and accurately and consistently focuses on efficient cutting dynamics at the nucleus (Fig. 5.37). The CustomControl Software II permits millisecond level control of ultrasound application, with optimized 28.5 kHz frequency cavitation for rapid emulsification. Precise control of power modulation for customized energy wave patterns results in low overall phaco time.

Overall ultrasound energy released in the eye correlates with handpiece operating frequency – the higher the frequency, the higher the energy dose.

The lower 28.5 kHz frequency allows for optimized cavitation and rapid emulsification with minimal thermal loading. Also, an increased stroke length permits more efficient cutting of the nucleus.

Dual linear simultaneous foot pedal control of aspiration and ultrasound enhances surgical safety (Fig. 5.38).

Fig.5.37 The ergonomic six crystal handpiece is easy to hold and manipulate

Fig. 5.38 The wireless dual linear foot pedal increases flexibility in the OR and provides increased surgical control

Both the surgeon and OR staff will enjoy the convenience and freedom of the Wireless Dual-Linear foot pedal. There is instantaneous response and control of critical intraoperative surgical parameters with no discernible lag. Of course, preprogrammable foot pedal settings are customizable to surgeon technique.

An intuitive interface and video overlay allows for ease of use by OR staff for set up and priming and fast OR turnaround. The Stellaris features a modular design for easy upgrades, and TruLink Customer Support Network connectivity. These features taken together make the Stellaris a truly twenty-first century phaco machine.

5.3.3.2Evaluating the Stellaris Vision Enhancement System

In order to assess the facility of use, safety and efficacy of the Stellaris Vision Enhancement System for bimanual micro incision cataract surgery, we undertook a prospective study of 30 unselected eyes of 26 patients presenting for cataract surgery with a single surgeon (MP) using the Advanced Flow System Vacuum Emulation (Table 5.6). Outcome measures included surgical time, Effective Phaco Time and Average Phaco Power, frequency of complications and uncorrected visual acuity at the first postoperative visit (either the same day or the next day).

The patient population was representative of our practice and included 13 women and 13 men with a mean age of 64.2 ± 8.3 years. The mean nucleus grade was 1.4 + NS. Among the group of subjects there were four eyes with a history of LASIK, one eye with pseudoexfoliative glaucoma, eye with pigment dispersion syndrome, one eye with strabismic amblyopia, two eyes with epiretinal membrane.

The surgical technique employed our current standard methods. The evolution of these techniques for bimanual micro incision phaco may be reviewed in a variety of publications [1–4]. Briefly, two single-plane 1.2–1.4mm trapezoidal incisions are made with a diamond knife about 60° apart in the temporal clear cornea. Aqueous is exchanged for a dispersive viscoelastic and a continuous curvilinear capsulorhexis is constructed with pinch type forceps. Following hydrodissection and hydrodelineation the nucleus is impaled, chopped and mobilized utilizing one of a variety of 20 gauge irrigating choppers and a 30° beveled straight phaco needle.