Phaco Handpiece Research Articles

Unexpected Intracameral Foreign Bodies During Regular Cataract Surgeries.

Unexpected intracameral foreign bodies during regular cataract surgery appear relatively often but seem to be underreported, since they are almost often immediately removed. They rarely remain in the anterior chamber and can be the source of inflammation, infections, or lead to corneal endothelial decompensation. We report two series of cases with different materials of different origins and review the literature. During several cases of uncomplicated phacoemulsifications under topical anesthesia, unknown foreign bodies visibly flushed in through the sleeve of the phaco handpiece. The material was always removed and submitted to the (Eidgenössische Materialprüfungs- und Forschungsanstalt; Federal Institute for Materials Testing and Research) for further investigations. Spectral analysis revealed that, in our cases, the foreign bodies were remnants of otherwise intact phaco sleeves that had not been cleaned properly during production. In another case series, the resin granules from the water filtration system for the instrument washing machine had found their way into the phaco handpieces. Many shapes and materials of different origins might unexpectedly appear during cataract surgery in the eye. Their immediate extraction is necessary, as they might cause corneal endothelial damage, chronic inflammation, or could be the source of infections. Vigilance reporting is also important for the controlling medicinal organizations and companies to assure early recognition of systematic problems.

Short-Cycle Autoclave Sterilization of Instruments in Same-Day Ophthalmic Surgeries

What Is the Issue? The volume of ophthalmic surgeries is increasingly high, with cataract surgery being 1 of the most performed surgeries in Canada. Infections following ophthalmic surgeries, while rare, can cause severe complications that may lead to irreversible vision loss. Reducing postsurgery infections is a high priority in clinical practice. Running a full wrapped, terminal steam sterilization cycle for ophthalmic instruments in autoclaves may be inefficient for ophthalmic surgeries and may cause unnecessary heavy economic and environmental burdens due to high surgical volumes. Using instruments sterilized on a short cycle between sequential same-day ophthalmic surgeries may help improve efficiency and reduce resources used. These instruments are generally processed using autoclaves (i.e., steam sterilizers); the effectiveness of a shorter-cycle method of sterilization is unclear. What Did We Do? To inform decisions regarding the use of autoclaves for short-cycle sterilization for sequential same-day instrument use in ophthalmic surgery, we sought to identify and summarize evidence comparing this method to full-cycle sterilization of wrapped instruments and identify any relevant recommendations. We searched key resources, including journal citation databases, and conducted a focused internet search for relevant evidence published since 2012. One reviewer screened articles for inclusion based on predefined criteria. What Did We Find? In a laboratory setting to simulate sequential same-day procedures, short-cycle sterilization with interrupted dry time for unwrapped ophthalmic instruments is feasibly as effective as full-cycle sterilization for wrapped instruments using the STATIM autoclave. Similarly, short-cycle sterilization with interrupted dry time for contained ophthalmic instruments is feasibly as effective as full-cycle sterilization for contained instruments using the AMSCO autoclave. For sequential same-day ophthalmic procedures, wet instruments sterilized by a short-cycle process with an interrupted dry time can remain sterile for at least 3 minutes if kept in a covered sterilizer containment device. One guideline recommends that wrapped or unwrapped ophthalmic instruments sterilized by a short-cycle process without full drying should be stored in a covered containment device until retrieved by staff wearing sterile gloves and gowns in the operating room for the subsequent surgery after a short delay. Phaco handpieces should be immediately primed with a balanced salt solution and remain wet as they sit on the sterile instrument table. We did not identify any clinical setting evidence from studies or autoclave manufacturers. It is unclear if clinical outcomes differ between patients undergoing sequential same-day ophthalmic surgeries using short-cycle sterilized instruments and those undergoing surgery using full-cycle sterilized instruments. What Does This Mean? Preliminary laboratory evidence and guideline recommendations supporting the use of autoclaves for short-cycle sterilization of instruments for sequential same-day ophthalmic surgeries are available. However, there is no clinical effectiveness evidence available on this process in patient settings. Future research is necessary to understand the clinical safety of using instruments sterilized by short cycles for sequential same-day use for patients undergoing ophthalmic surgeries. In addition to the evidence and recommendations identified, other factors, such as environmental influence, may be useful considerations when making decisions about short-cycle sterilization for sequential same-day instrument use for ophthalmic surgery.

Comparison of Phacoemulsification Grooving Efficiency in Longitudinal vs Transversal Handpieces.

To determine the difference, if any, in grooving efficiency at various settings on the Whitestar Signature Pro phacoemulsification (phaco) system. Cataractous lenses were simulated by exposing porcine lenses to formalin for 2 hours. A total of 120 lenses were analyzed at various power settings on both longitudinal and transversal handpieces. Twenty trials each were performed with power set to 25%, 50%, and 75% on both handpieces. A Whitestar Phaco Handpiece System was used to provide longitudinal power, and a Whitestar Signature Ellipsis Handpiece provided transversal power. Lenses were placed within a plastic chamber and grooved by an investigator blinded to settings. A second investigator recorded times and adjusted settings. The Whitestar Signature Pro phaco system was used for grooving. There was no significant difference in grooving times between the longitudinal and transverse handpieces at any power setting (P > 0.05). There was a significant decrease in grooving times when comparing the 25% power setting with the 75% power setting for the transversal handpiece (P=0.021). Both longitudinal and transversal handpieces on the Whitestar Signature Pro phaco system produce similar results to one another at each power setting. There is a general trend toward shorter grooving times, reflecting greater efficiency, at higher power settings. Grooving efficiency on the transversal handpiece may be more affected by changes in the power settings as compared with the longitudinal settings.

Incidence of Incision-Related Descemet Membrane Detachment Using Phacoemulsification With Trapezoid vs Conventional 2.2-mm Clear Corneal Incision

The conventional 2.2-mm clear corneal incision is relatively narrow compared with the sleeves of Phaco handpieces, resulting in friction at the incision site and increased risk of incision-related Descemet membrane detachment (DMD). The modified 2.2-mm incision only enlarged internal width to 3.0 mm, forming a trapezoid incision shape, which may reduce the friction of surgical instruments and decrease the risk of incisional DMD. To compare the incidence of incision-related DMD between eyes undergoing modified vs conventional 2.2-mm incision phacoemulsification for hard nuclear age-related cataract. This double-masked, parallel randomized clinical trial was conducted from July 22, 2019, to January 22, 2020, at Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China. The study included patients with age-related cataract and nuclear opalescence grade of 4.0 or greater based on the Lens Opacities Classification System III. Patients were enrolled in this study according to the following inclusion criteria: (1) age between 65 to 90 years; (2) pupil size of 6 mm or greater after dilation; (3) Lens Opacities Classification System III nuclear opalescence grade of 4.0 or more; and (4) corneal endothelial cell density greater than 1500 cells/mm2. Modified (enlarged internal width to 3.0 mm) or conventional 2.2-mm incision phacoemulsification with intraocular lens implantation. Incidence of incision-related DMD at postoperative day 1. A total of 130 eyes of 130 patients were randomized into the conventional group (n = 65) or the modified group (n = 65). The mean (SD) age of participants was 74.5 (5.9) years and 74.3 (6.0) years in the conventional and modified groups, respectively. A total of 26 participants in the conventional group (40%) and 27 in the modified group (42%) were men. Compared with eyes in the conventional group, the incidence of DMD in eyes in the modified group was significantly lower at postoperative day 1 (difference, 26.15; 95% CI, 9.60-42.71; P = .003). The difference at postoperative day 7 was 16.92 (95% CI, 2.91-30.94; P = .02). The length of DMD (postoperative day 1: difference, 0.188; 95% CI, 0.075-0.301; P = .002) and maximal corneal thickness at incision site (postoperative day 1: difference, 0.032; 95% CI, 0.006-0.057; P = .02; postoperative day 7: difference, 0.019; 95% CI, 0.003-0.035; P = .02) were lower in the modified group, while visual quality parameter modulation transfer function (postoperative day 1: difference, -0.033; 95% CI, -0.064 to -0.001; P = .04) was higher. No difference was observed between the 2 groups in best-corrected visual acuity, central corneal endothelium loss, or surgically induced astigmatism at any follow-up time. There were no intraoperative complications in the 2 groups. These findings suggest that modified 2.2-mm trapezoid incision phacoemulsification reduces the incidence of DMD for hard nuclear age-related cataract at postoperative day 1 and might be considered in patients at high risk of incision-related DMD, although the clinical relevance cannot be determined with certainty from this trial. ClinicalTrials.gov identifier: NCT04014699.

Visual outcomes in the management of dropped nucleus without using the fragmatome

Background: Phacoemulsification (Phaco) and intraocular lens implantation is the commonest surgical practice for the treatment of cataract. Posterior capsular rupture and dropping the nucleus into the vitreous is one of the less common but sight threating complication of phacoemulsification. Trans pars plana posterior vitrectomy (TPPV), removal of the dropped lens fragments and insertion of an intraocular lens is the preferred treatment option for the above complication. The intraocular lens may be placed in the sulcus where capsular ring is intact or scleral fixation is done in the case of absent capsular ring. Methodology: This study is a retrospective review of patients who had TPPV, removal of the lens fragments through the corneal incision using torsional phaco hand piece and sulcus insertion of multipiece intraocular lens (IOL) as the treatment for dropped lens fragments complicating cataract surgery at Nawaloka Hospitals PLC, Colombo, Sri Lanka. Forty four consecutive patients who underwent TPPV from January 2018 to December 2019 have been studied. The notes on the medical records at the initial presentation, second and eighth week post vitrectomy records were reviewed. Results: Forty four patients were reviewed within the 24-month period. There were 30 (68.2%) males and 14 (31.8%) females. All the patients were operated within a week after phacoemulsification. The best corrected visual acuity was 6/9 or better in 33 (75%) eyes at two weeks and 8 weeks post-surgery. There were no major complications observed in the series. Conclusion: Dropped nucleus following phacoemulsification can be managed by removal of the lens through the corneal incision using phaco handpiece with good visual outcomes.

Testing a Novel Device for Accurate Ultrasound Delivery During Crystalline Lens Phacoemulsification Surgery.

PurposeTo assess whether the use of a patented, novel feedback device intended to accurately control phacoemulsification tip elongation is effective under varying machine settings and material resistance.MethodsSculpt mode phaco (550-mm Hg Venturi pump; elongations, 35 and 70 µm) and quadrant settings (550-mm Hg Venturi pump; elongations, 15, 30, and 60 µm) were used in agar gel of incremental density (1%, 2%, 3%, and 6% in demineralized water). Dispersed lens fragments were also simulated with 6% agar gel spherules (2–5 mm in diameter; 550-mm Hg vacuum, and 60-µm elongation). Actual phaco tip elongation was measured on voltage readings from the piezoelectric crystals and compared to nominal elongation with feedback control off and on.ResultsMismatch between nominal and actual elongation when feedback control was off in sculpt mode varied between –13.51 µm and –23.07 µm of nominal elongation; in quadrant mode, mismatch varied between –2.79 µm and –20.41 µm. When the feedback control system was switched on, mismatch varied between –0.02 µm and +0.43 µm (P < 0.001 for all matchings). When the feedback system was off, the elongation mismatch among the 1%, 3%, and 6% agar was also statistically significant (P < 0.001). Elongation was 44.72 ± 4.16 µm with feedback control off and 60.02 ± 1.63 µm with it on (nominal elongation 60 µm; P < 0.001) when emulsifying agar 6% gel fragments. Dispersion of elongation data was also significantly wider when feedback control was turned off.ConclusionsA novel feedback control system effectively controls elongation accuracy regardless of the resistance offered by incremental agar gel concentrations.Translational RelevanceImplementing feedback control in phaco handpieces dramatically improves surgical accuracy. The translational value of this research relies on its immediate applicability to routine cataract surgery, resulting in a more appropriate use of ultrasound energy.

Evaluation of Ophthalmic Surgical Instrument Sterility Using Short-Cycle Sterilization for Sequential Same-Day Use

The common practice of short-cycle sterilization for ophthalmic surgical instrumentation has come under increased regulatory scrutiny. This study was undertaken to evaluate the efficacy of short-cycle sterilization processing for consecutive same-day cataract procedures. Testing of specific sterilization processing methods by an independent medical device validation testing laboratory. Phaco handpieces from 3 separate manufacturers were tested along with appropriate biologic indicators and controls using 2 common steam sterilizers. A STATIM 2000 sterilizer (SciCan, Canonsburg, PA) with the STATIM metal cassette, and an AMSCO Century V116 pre-vacuum sterilizer (STERIS, Mentor, OH) using a Case Medical SteriTite container (Case Medical, South Hackensack, NJ) rigid container were tested using phaco tips and handpieces from 3 different manufacturers. Biological indicators were inoculated with highly resistant Geobacillus stearothermophilus, and each sterility verification test was performed in triplicate. Both wrapped and contained loads were tested with full dry cycles and a 7-day storage time to simulate prolonged storage. In adherence with the manufacturers' instructions for use (IFU), short cycles (3.0-3.5-minute exposure times) for unwrapped and contained loads were also tested after only 1 minute of dry time to simulate use on a consecutive case. Additional studies were performed to demonstrate whether any moisture present in the load containing phaco handpieces postprocessing was sterile and would affect the sterility of the contents after a 3-minute transit/storage time. This approximated the upper limit of time needed to transfer a containment device to the operating room. Presence or absence of microbial growth from cultured test samples. All inoculated test samples from both sterilizers were negative for growth of the target organism whether the full dry phase was interrupted or not. Pipetted postprocessing moisture samples and swabs of the handpieces were also negative for growth after a 3-minute transit/storage time. These studies support the use of unwrapped, short-cycle sterilization that adheres to the IFU of these 2 popular Food and Drug Administration-cleared sterilizers for sequential same-day cataract surgeries. A full drying phase is not necessary when the instruments are kept within the covered sterilizer containment device for prompt use on a sequential case.

Robotic surgery ‐ a new way to perform cataract surgery

PurposeTo demonstrate the feasibility of robot‐assisted simulated cataract surgeryMethodsWe performed cataract surgeries on a Kitaro cataract wet lab training system using simultaneously the DaVinci Xi robotic surgical system and a phacoemulsification system. For each procedure, duration and successful completion of the surgery with or without ocular complications were assessed.ResultsProcedures were successfully performed on 27 lens nuclei. Feasibility of robot‐assisted simulated cataract surgery is confirmed. The DaVinci Xi system provided the intraocular dexterity and operative field visualization necessary to perform the main steps of the phacoemulsification procedure: corneal incisions, capsulorhexis, grooving, cracking, quadrant removal and infusion‐aspiration of the viscoelastic. The intervention of a second surgeon was required for the intraocular injections of viscoelastic, balanced salt solution and intraocular lenses. Mean operative time was 26 minutes. All lens nuclei were removed. Inadvertent enlargement of the main corneal incision caused by the phaco hand piece was observed in 2 cases.ConclusionsExperimental robot‐assisted cataract surgery is technically feasible using the new DaVinci Xi robotic Surgical System combined with a phacoemulsification machine.

Chemical and physical analysis of phaco handpiece tip surfaces before and after cataract surgery

To evaluate the surface chemical composition and roughness of different phaco tips before and after their use during cataract surgery. Eye Clinic, University of Trieste, Trieste, Italy. Experimental study. Of the 66 tips studied, 33 (15 new, 15 after single use, and 3 after multiple uses) were studied with X-ray photoemission spectroscopy and 33 (15 new, 15 after single use, and 3 after multiple uses) were examined using scanning electron microscopy with energy dispersive X-ray spectroscopy analysis and contact profilometry. All analyses were performed on the far end of the tip. Used phaco tips showed signs of wear at the end of the tip, with the deposition of debris. The cutting edge appeared to be rounded and irregular. After surgery, an increase in the surface roughness was detected. The chemical analyses showed modification of the superficial alloy composition and the biological origin of some debris deposited after surgery. The deterioration and wear observed were more remarkable after multiple surgical procedures. Used phaco tips showed relevant signs of deterioration and deposition of biological material, mostly involving the cutting edge. Reusable tips might release remnants of previous procedures. The adoption of single-use disposable phaco tips seems to be highly advisable.

Robot-assisted simulated cataract surgery

To evaluate the feasibility of robot-assisted simulated cataract surgery. Institut de Recherche Contre les Cancers de l'Appareil Digestif, European Institute of Telesurgery, and Strasbourg University Hospital, Strasbourg, France. Experimental study. Cataract surgeries were performed on a Kitaro cataract wet-lab training system simultaneously using the Da Vinci Xi robotic surgical system and the Whitestar Signature phacoemulsification system. For each procedure, the duration and successful completion of the surgery with or without ocular complications were assessed. Procedures were successfully performed on 25 lens nuclei. The feasibility of robot-assisted simulated cataract surgery was confirmed. The robotic surgical system provided the intraocular dexterity and operative field visualization necessary to perform the main steps of the phacoemulsification procedure; that is, corneal incisions, capsulorhexis, grooving, cracking, quadrant removal, and irrigation/aspiration of the ophthalmic viscosurgical device (OVD). The intervention of a second surgeon was required for the intraocular injections of OVD, balanced salt solution, and intraocular lenses. The mean operative time was 26.44minutes±5.15 (SD). All lens nuclei were removed. Inadvertent enlargement of the main corneal incision caused by the phaco handpiece was observed in 2cases. Experimental robot-assisted cataract surgery was technically feasible using the new robotic surgical system combined with a phacoemulsification machine.

Case study on the orientation of phaco hand pieces during steam sterilization processes

Steam sterilization is an essential part of infection prevention. The literature shows that sterilization of medical instruments containing channels is not trivial. Phaco hand pieces have a simple configuration: a device contains a channel with a constant radius. No literature was found indicating whether the sterilization conditions on the inner surface of a phaco hand piece are influenced by the orientation of the hand piece. To determine whether the orientation of a phaco hand piece influences the results of a sterilization process of this device. A qualitative case study, including experiments, is performed with a protocolled combination of steam sterilizer, process, phaco hand piece, orientation of the phaco hand piece, and wrapping. In this specific case, the orientation of the hand piece influenced the result of the steam sterilization process; in vertically (upright) oriented phaco hand pieces with free water drainage, sterilization conditions are reproducibly established. In the same process, in horizontally oriented or vertically oriented hand pieces without free drainage, these conditions are not established in a reproducible way. In the investigated combination of sterilizer, process, load, loading pattern and wrapping, phaco hand pieces have to be oriented vertically (upright) with free water drainage to obtain steam sterilization conditions on the inner surface. It is likely that instruments with comparable configuration and dimensions will yield comparable results. It is therefore recommended that this issue is considered during the development of medical instruments and during performance qualifications of such instruments.

Fluid dynamics and intraocular pressure using venturi phacoemulsification machine in dogs ex vivo.

To optimize fluid dynamics through measuring intraocular pressure (IOP) in a venturi phacoemulsification machine in dogs. In step I, flow and IOP of the test chamber were measured using a pressure transducer with the bottle height (BH) set at 50, 70, 100, and 120 cm and the vacuum from 30 to 450 mmHg. A 19-gauge phaco and a 0.3-mm irrigation/aspiration (I/A) handpiece were used. In step II, flow and IOP were measured in an enucleated canine eye with a 3.0- and a 3.2-mm clear corneal incision (CCI), respectively. IOP was measured using the pressure transducer at a 30-mmHg vacuum to allow corneal deformation, to define the fluidic parameters for preventing surge. Flow was directly proportional to the BH and vacuum, whereas IOP was directly proportional to the BH and inversely to the vacuum. Flow with an I/A handpiece was significantly less than with a phaco handpiece, explaining why IOP with an I/A handpiece was significantly higher than with a phaco handpiece. With the I/A handpiece, vacuum parameters less than 450 mmHg did not result in corneal deformation. IOP with a 3.2-mm CCI was significantly lower than with a 3.0-mm CCI, with the 3.2-mm flow being greater than the 3.0-mm flow. BH during the I/A stage could be reduced to avoid unnecessary stress on the canine eye when using a venturi system. Although phacoemulsification with a 3.2-mm CCI could induce lower IOP, a 3.0-mm CCI might lessen the irrigation flow stress on the eye.

Acute Endophthalmitis Following Cataract Surgery Via Contaminated Phaco Tip

Cataract is one of the most common causes of visual impairment [1]. It is estimated that there are approximately 30 million blind people in the world and 50 percent of them are blind due to cataracts [2]. The only treatment for cataract is surgery and modern surgical techniques are extremely safe with few major complications [3]. Endophthalmitis is a severe intraocular inflammation which may occur as a serious complication of cataract surgery [4]. In our hospital cataract surgery has been performed since 2003. Over one thousand five hundred cataract operation was performed in our hospital by the same ophthalmologist. This was the first case and also outbreak by this time. Endophthalmitis was occurred in four cases following cataract surgery. The surgery was consecutively performed on the same day. All the patients were over 65 years old. Their past medical history included hypertension, heart failure, Parkinson disease and chronic obstructive pulmonary disease. All four patients were admitted to the hospital on the day of surgery. Implantation of a foldable intraocular lens through clear corneal incision was performed under local and topical anesthesia. Prophylactic antibiotics were not administered in the preoperative and perioperative period. There was no complication occurred during surgery and patients were discharged following the surgery. But on the second day after the surgery all four patients complaining about eye pain and decreasing vision. On physical examination slightly swollen eyelids, decreased visual acuity and hypopyon was revealed. The view of the retina was hazy on ophthalmological examination. The time between cataract surgery and the diagnosis of endophthalmitis was twenty four hours. Multiple cultures were obtained from all parts of phacoemulsifier on the same day of the outbreak by infection control team. All the patients received prednisolone sodium phosphate, moxifloxacin hydrochloride, cyclopentolate hydrochloride and vancomycin drops by topical route, vancomycin and gentamicin by subkonjunctival route vancomycin and ciprofloxacin by intravenous route. On the second day of initial treatment signs and symptoms of the patients started to recover dramatically. After follow up of seven days all patients hypopyon have resolved with improved vitritis and inflammation decreased and eventually visual activity corrected. During the outbreak we focused on the surgical devices because nosocomial surgical infections were considered to be the result of contaminated surgical sites with inadequately sterilized surgical instruments. We obtained cultures from recent sterilized hydrodissection cannula, capsulorhexis forceps, phaco tip, phaco handpiece, and aspiration and irrigation hose. They were all inoculated into blood, chocolate and eosin methylene blue agar. Koagulase negative staphylococcus was isolated from an aseptically obtained culture of phaco tip. Other culture results were reported negative. We did not able to sample vitreous and aqueous humor. Most cases of endophthalmitis present acutely with hours to a few days of symptoms. Coagulase negative staphylococci (70% of patients) are the most common causes of postcataract endophthalmitis [5]. Bacterilogical diagnostic similarities among samples from patients with endophthalmitis and surveillance species have not been shown. This was the crucial limitation of the report. In this outbreak when we investigate the cause of the infections we realized that all phaco tips have disappeared except one that was used during the cataract surgery of four cases and operating staff was keeping it in a tube. This tube presumably didn’t allow adequate decontamination and sterilization. We aimed to share an outbreak experience. This report demonstrates the importance of well organization and close collaboration between sterile service providers, operating staff, infection control team and operator for reducing the risk of surgical infections.

Phacoemulsification Systems

Phacoemulsification Systems

Determination of the nature and origin of the metallic foreign particles appearing on the iris after phacoemulsification

To determine the nature and the origin of metallic foreign particles appearing on the iris after phacoemulsification surgery. P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India. Case series. Metallic foreign particles were observed on the iris surface and the pupillary border on the first postoperative visit after phacoemulsification. One metallic particle, which was stuck to the iris surface, was removed intraoperatively and sent for metal analysis along with the phaco needle, the wrench used to tighten the phaco needle to the phaco handpiece, and the anterior chamber maintainer used during phacoemulsification. The composition of the elements was studied by scanning electron microscopy (SEM) to determine the origin of the metallic particle. Foreign particles were seen in 11 eyes. On SEM, 3 elements (carbon, magnesium, and silicone) were common in the metal particle and 4 elements (carbon, magnesium, silicone, and titanium) on the wrench. The elements in the phaco needle (titanium) and anterior chamber maintainer (manganese, iron, and nickel) did not match those in the metal particle. The metal contents of the metallic particle extracted from the eye matched some of the constituent metals of the wrench that was used to tighten the phaco needle on the handpiece just before surgery. No author has a financial or proprietary interest in any material or method mentioned.

Utilizing the Productivity Analysis Module

Utilizing the Productivity Analysis Module

Biaxial microincision versus coaxial small-incision cataract surgery in complicated cases

To evaluate and compare the results of biaxial microincision and coaxial small-incision surgery in patients with cataract with coexisting exfoliation syndrome, uveitis, anterior or posterior synechias, phacodonesis, or previous intraocular surgery over an 8-week follow-up. Department of Ophthalmology, Mainz University, Mainz, Germany. Eyes were prospectively assigned (1:1) to have biaxial microincision (<1.5 mm) phacoemulsification or coaxial small-incision (2.8 mm) phacoemulsification using pulsed ultrasound energy (Sovereign WhiteStar) with variable duty cycles followed by implantation of a microincision intraocular lens. Intraoperative and postoperative complications, corrected distance visual acuity (CDVA), laser flare photometry values, effective phacoemulsification time (EPT), and endothelial cell count (ECC) were evaluated. The study enrolled 94 eyes. There were no statistically significant differences between the techniques in intraoperative or postoperative complications. The most frequent postoperative complications were corneal edema surrounding the incision (40%, biaxial group; 35%, coaxial group), pupil distortion (3% versus 7%), and fibrin exudation (3% versus 3%). No other postoperative complications occurred. The median EPT was statistically significantly shorter (1.34 seconds versus 5.4 seconds) and the median phaco power significantly lower (3.3% versus 12.9%) in the biaxial group than in the coaxial group (P<.001). There were no differences between groups in CDVA, laser flare photometry values, or ECC. The EPT was shorter and the mean phaco power lower with biaxial phacoemulsification, perhaps because of better access of the phaco handpiece for grooving the nucleus with this technique. The 2 techniques were comparable in intraoperative and postoperative complications. No other author has a financial or proprietary interest in any material or method mentioned.

Postoperative Endophthalmitis: Caution is the Watchword

Postoperative endophthalmitis is the most feared complication following cataract surgery. It can be caused by infection entering the eye during surgery or by inadequately cleaned instruments. Sterile phaco handpieces might retain remnants of soft lens matter or visco-elastic which might later contaminate other patients, causing inflammation in their eyes. The costs of an endophthalmitis outbreak are heavy, including poor patient outcomes, temporary theatre closure, rising waiting lists and damage to a hospital's reputation. This article raises awareness of endophthalmitis and provides useful recommendations for ophthalmic theatre personnel.

Intravitreal phacoemulsification with pars plana vitrectomy and posterior chamber intraocular lens suture fixation for dislocated crystalline lenses

This technique to manage a dislocated crystalline lens comprises intravitreal phacoemulsification with transscleral suture fixation of a posterior chamber intraocular lens (IOL). The dislocated lens in the vitreous cavity is removed using a standard phaco handpiece with the assistance of a fiber-optic light pipe. Then, the IOL is implanted. The technique was used in 10 eyes of 8 patients with lens luxation or subluxation. The postoperative best corrected visual acuity was 20/25 or better except in 1 eye, and no serious complications were observed. Increased intraocular pressure before surgery in 4 eyes was normalized in 3 eyes.

Metallic fragment deposits during phacoemulsification

Purpose: To describe the nature and origin of foreign metallic intraocular bodies appearing after phacoemulsificationSetting: Department of Ophthalmology, versity Hospital of Sairtera, Spain.Methods: Two metallic particles, 1 extracted during surgery and the other from a patient in whom surgery had been performed, were studied by scanning electronic microscopy and X-ray dispersive energy spectroscopy. Also evaluated were all metallic elements used in phacoemulsification including phaco tips, Sinskey hooks, and handpieces. A morphologic analysis at various magnifications was performed and the composition of the elements studied.Results: Scanning electronic microscopy showed irregularities of the phaco tip and Sinskey hook after their use. Spectrographic analysis found that the phaco tip was mainly aluminum and titanium; the Sinskey hook, iron, chromium, cobalt, and nickel; the handpiece, iron, chromium, and nickel; and the 2 metallic particles, iron, chromium, and nickel, the same as the handpiece.Conclusion: The metallic particles extracted corresponded to those of the phaco handpiece. Vibration during prolonged use of the phacoemulsifier probably caused these particles to chip off the handpiece.