EyeWorld Asia-Pacific December 2019 Issue

36 EWAP DECEMBER 2019 CATARACT by Liz Hillman EyeWorld Senior Staff Writer T here are a number of new technologies making their mark in cataract surgery. Among them are Zepto (Mynosys), miLOOP (Carl Zeiss Meditec), and the Light Adjustable Lens (RxSight). Kevin Waltz, MD, Susan MacDonald, MD, and Bennett Walton, MD, offered their insights on these technologies. Automating the capsulotomy Creating a continuous curvilinear capsulorhexis manually is one of the most fundamental aspects of cataract surgery training, but there are a number of technologies that are automating this part of the procedure. The femtosecond laser is one example, but a more recently approved device with a smaller footprint is Zepto (FDA approved in 2017), which consists of a collapsible nitinol ring, a silicone suction cup, and an energy source that heats the nitinol ring and water molecules that are trapped in the suction cup, creating the capsulotomy. CAPSULaser (Excel-Lens) is another automated capsulotomy device, but it is not yet approved by the U.S. FDA. Dr. Waltz has been working with Zepto since 2015, initially as the principal investigator for ̅i `iۈVi½Ã wÀÃÌ ˆ˜‡…Õ“>˜ ÌÀˆ>Ã in El Salvador. While the main purpose of Zepto is to create consistently sized, perfectly round, and reproducible capsulotomies centered on the visual axis, Dr. Waltz said the device provides a number of advantages beyond its original intent. One that’s been documented in peer-reviewed literature is improved capsule strength. As Dr. Waltz said and as scanning electron micrographs show, Zepto creates a slight upturn in the capsular edge at the cut. Capsule edge tear strength from capsulotomies created with Zepto, femto, and manually have been compared, and Zepto- VÀi>Ìi` ÜiÀi vœÕ˜` È}˜ˆwV>˜ÌÞ more resistant to tearing. 1 Dr. Waltz said there is i>ÀÞ] ՘Vœ˜wÀ“i`] È}˜>Ã suggestioning Zepto decreases the burden of epithelial cells remaining in the eye after surgery. He said long-term monitoring of patients in El Salvador, where you would expect to see a higher rate of PCO, show a low rate of PCO with Zepto. Dr. Waltz hypothesized that the vacuum release of the capsulotomy helps the surgeon do a thorough and effective hydrodissection that appears to “change the biology of the healing.” Compared to the femtosecond laser, Zepto has advantages in price and footprint. Cortex removal, Dr. Waltz said, is easier with Zepto- created capsulotomies, while it’s harder with femtosecond laser-created capsulotomies. Advantages of the laser systems, Dr. Waltz noted, is that some are able to match the visual axis to markers on the capsule, and they can make astigmatic cuts. But the femtosecond laser and Zepto are not mutually exclusive, Dr. Waltz said, noting that some surgeons who offer femtosecond laser-assisted cataract surgery have found Zepto to be an attractive alternative upgrade for patients who cannot or do not wish to spend what FLACS would cost. Dr. Waltz said he is currently transitioning his main practice from El Salvador back to Indianapolis where he will use Zepto when he thinks it’s Li˜iwVˆ> ̜ ̅i «>̈i˜Ì° 7…ˆi some surgeons use mechanical devices like Zepto in every case to get a perfectly centered and sized capsulotomy to reduce higher order aberrations and lead to more predictable outcomes, Dr. Waltz said others will use it in more complicated cases, such as those with zonulopathy or white cataracts. Dr. Waltz provided a couple of pearls for Zepto success. First, he said you have to withdraw the pushrod of the device fully before applying vacuum; if you don’t, the vacuum is inadequate and you could get an incomplete cut. Second, give the vacuum time to develop. The vaccum creates bubbles inside of the system. These bubbles move while the vaccum is building. The vaccum is being pulled through 8 feet of tubing and it takes a few seconds to fully develop the vaccum inside of the eye. Dr. Waltz said once the bubbles in the eye stop moving, the vacuum is fully engaged. New instrumentation for cataract surgery Contact information MacDonald: susanmacdonaldeyecorps@gmail.com Walton: drwalton@visiontexas.com Waltz: kwaltz56@gmail.com This article originally appeared in the September 2019 issue of EyeWorld . +V JCU DGGP UNKIJVN[ OQFKƂGF CPF appears here with permission from the ASCRS Ophthalmic Services Corp.