EyeWorld Asia-Pacific December 2018 Issue

December 2018 EWAP FEATURE 23 “Zepto has become a major part of my procedures,” Dr. Kretz said. “It is the premium procedure for patients not able to afford FLACS [femtosecond laser-assisted cataract surgery].” Dr. Kretz uses Zepto in pa- tients with severe zonular disor- ders where he needs additional zonular support and in patients where he expects phimosis, such as young children and those with retinitis pigmentosa. Surgeons can use Zepto on patients with small pupils, white cataracts, and other complicated cases, with the only limitation being an anterior chamber depth of at least 1.8 mil- limeters, he said. Zepto offers a significant ad- vantage when operating on white cataracts, according to Drs. Waltz and Swan. “Here is the classic situation that you worry about with a white cataract: You’re worried about it being under some tension so when you put a little hole in it, you might get an extension, and you get an Argentinian flag sign,” Dr. Waltz said. “With Zepto, it cuts the 360-degree hole simultane- ously, so you get instantaneous release of the pressure. You don’t have to worry about an Argentin- ian flag sign.” “Because you have a 4-mil- lisecond capsulotomy, I am even more comfortable [with Zepto] than with the femto, and the strength and stability of the capsule with it is fantastic,” Dr. Swan said. “I think that it’s a game changer there.” Zepto can even provide benefits for pediatric cataracts. Be- cause pediatric capsules are much more elastic and behave differ- ently during surgery, creating the capsulotomy is difficult. But Zepto has the potential to make these surgeries faster, easier, and safer for the patient, according to Da- vid Sretavan, MD, co-founder of Mynosys. “We’ve had a lot of pediat- ric cataract surgeons contact us because they see this as a use- ful tool to help them create that capsulotomy,” he said. “We’d like to address that. It requires a bit of engineering in terms of coming up with a device that will create a capsulotomy of the appropriate size, but that is something that the company intends to do fairly soon.” One unexpected benefit of the device is that because the silicone suction cup is transparent, Zepto allows the surgeon to preserve visual axis information typically lost during surgery. “Everyone has his or her unique visual axis, and Zepto al- lows the surgeon to customize the placement of the capsulotomy to fit the visual axis of that particular patient,” Dr. Sretavan said. “That’s a benefit of a Zepto capsulotomy, and it feeds into the concept that Zepto is much more than just a capsulotomy device; it has benefits through many different important stages of cataract surgery.” Advantages to the surgeon By making complex cases routine and routine cases more consistent, Zepto allows seasoned ophthal- mologists to extend their surgical careers, according to Dr. Waltz. “One of the things that causes people to retire from surgery is inability or [discomfort] achiev- ing a consistent capsulotomy,” Dr. Waltz said. “We’ve had a number of mature surgeons say, ‘This is important for me because I’m go- ing to be able to operate for years longer because now I can be as- sured of my capsulotomy; the rest of it I’m comfortable with, but I was becoming uncomfortable with my capsulotomy.’” Dr. Swan sees it as a “definite go-to” for any refractive or premi- um case. “I think a well-centered capsulotomy that has great optic overlap is important to give the best refractive outcome, and I think it’s a nice add-on for those cases,” he said. Many surgeons have noticed that after creating a Zepto capsu- lotomy, it’s as if the hydrodissec- tion is almost or fully complete, and they need to do very little in terms of fluid injection to get the lens to spin and rotate freely, ac- cording to Dr. Sretavan. Zepto requires suction to make the capsulotomy, and when the capsulotomy is complete, that suc- tion is released by reintroducing OVD and balanced salt solution into the capsular bag, which cre- ates a 360-degree enclosed hy- drodissection effect as part of the device’s removal. “That has been a benefit that surgeons have told us that they’re seeing, and Mynosys will be optimizing that into Zepto so that more surgeons will have that affect and it will become a reliable result from a Zepto capsulotomy,” Dr. Sretavan said. The effortless hydrodissection improves healing, which helps prevent postoperative posterior capsule opacification (PCO), ac- cording to Dr. Kretz. In addition, the micropulse vibrations that cre- ate the capsulotomy help loosen epithelial cells from the capsule, which also helps prevent PCO after surgery, he said. Zepto vs. femto The surgeons agree that Zepto and femto are complementary devices for creating automated capsul- otomies. While there is overlap continued on page 24