Supplement November 2011

17 September 2011xxix Congress of the ESCRS

ViennaTake your Practice to a New Levelwith the ZEiSS MiCS Platform

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Introduction

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Microincision cataract surgery (MICS) is a significant advance for improving outcomes in cataract surgery. Intraoperatively, the technique affords improved control, increasing safety and making MICS particularly useful in challenging cases.

Postoperatively, patients achieve faster and better visual recovery thanks to the smaller, astigmatically neutral incision.

However, operating through a smaller incision can place increased demands on the phacoemulsification platform, and maintaining the benefits of a microincision and providing patients with excellent vision depends on the availability of high-quality IOLs that can be delivered through an unenlarged incision.

In a symposium held during the XXIX Congress of the ESCRS, leading cataract surgeons discussed how these challenges are successfully addressed by the ZEISS MICS Platform.

Take your Practice to a New Level with the ZEISS MICS Platform

BLUEMIXS 180 Injector for Preloaded MICS IOLs – New Perspectives for Today’s Modern Cataract Surgery

Use of the preloaded CT ASPHINA® 409MP IOL that comes with the single-use BLUEMIXS® 180 injector (Carl Zeiss) enhances the safety and ease of MICS techniques and is providing excellent outcomes in a growing series of

patients, according to Paul Mullaney MD.The CT ASPHINA 409MP is a single-piece, monofocal, aspheric

(aberration neutral) hydrophilic acrylic (25 per cent water content) lens with a hydrophobic surface available in dioptric powers ranging from 0.0 to +32.0 D. Preloaded in the BLUEMIXS 180 injector, it can be delivered through a 1.8mm microincision.

Dr Mullaney said he first implanted the preloaded lens in October, 2010, and through September, 2011, he has used it in more than 1500 cases. Overall, taking into account his experience, feedback from the OR staff, and patient outcomes, his impressions are very favourable.

“I was initially skeptical about the purported advantages of MICS, which I thought was chasing the Holy Grail for a smaller incision, and I also questioned the benefits of a preloaded IOL. Now I appreciate both are advances for surgeons and patients,” said Dr Mullaney, consultant ophthalmologist, Sligo General Hospital, Sligo, Ireland.

“The microincision affords increased anterior chamber stability intraoperatively, and use of the preloaded CT ASPHINA 409MP IOL maintains the benefits of the microincision for minimising surgically induced astigmatism (SIA) and increasing patient comfort postoperatively. Together they are a winning combination for achieving satisfied patients.”

Dr Mullaney said both he and his staff appreciate the convenience of the preloaded technology that increases surgical efficiency and avoids any potential for loading errors by the scrub nurse, while also reducing contamination risk.

“The preloaded system makes the task of IOL handling much easier for our presbyopic nurses and leaves me assured that the lens will deliver properly every time, without damaged or distorted haptics,” Dr Mullaney noted.

He added that using the BLUEMIXS 180 injector, the IOL is delivered with controlled and linear viscoinjection, and with the single-piece design of the CT ASPHINA 409MP, there is less risk of causing posterior capsule damage by the trailing or leading haptics that can occur when implanting a three-piece lens.

“The ease of use and safety benefits also makes the preloaded CT ASPHINA 409MP an excellent platform for training residents,” Dr Mullaney said.

Reviewing his technique for lens delivery using the BLUEMIXS 180 injector, Dr Mullaney said he operates through a standard incision constructed with a three-step technique to create a square architecture. When ready to implant the lens, he places the injector bevel down on the posterior lip of the wound and advances it forward using a repetitive, left-to-right twisting motion of the injector. This manoeuvre allows the injector tip to track its way into the incision. Advancement is stopped when he feels a slight amount of resistance, which indicates the injector tip has reached the level of Descemet’s membrane.

Paul Mullaney

CT ASPHINA 409MP

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Dr Mullaney described two techniques for delivering the IOL. His preferred method is to use the injector to rotate the eye up to a vertical position. This causes the cornea to flip over the superior aspect of the injector and allows the tip to be moved 2-3mm further into the anterior chamber so that the lens can be released into the capsular bag where it nicely unfolds.

Alternatively, the lens can be injected once the tip of the introducer has reached Descemet’s membrane, in which case the lens will be released diagonally in the anterior chamber with the base of the lens in the inferior portion of the capsular bag. It can then be tapped gently into position in the capsular bag using a bimanual I&A tip.

“When first advancing the injector, I stop at Descemet’s membrane because attempting to move it further risks stromal dissection. I prefer the first technique for delivering the lens because it enables in-the-bag placement in a single manoeuvre, which has been achievable in about 80 per cent of cases,” Dr Mullaney said.

“If the lens is introduced without the injector entering the anterior chamber, because of the downward angulation of the eye, complete placement in the bag is unlikely with a single manoeuvre.”

With the MICS procedure, patients enjoy good postoperative comfort, and they have been very happy with the quality of their vision. There have been no postoperative complications in this relatively large series, and although follow-up is short, the lenses are very stable, and there is no evidence for increased posterior capsule opacification (PCO).

“Improved patient comfort has been one of the big benefits I’ve noticed after MICS. Complaints of a foreign body sensation, presumably due to the lip effect of the incision, are now rare, but were common among patients operated by using incisions larger than 2.8mm,” Dr Mullaney said.

“The potential for more PCO is one worry I have with MICS, and I did experience problems with significant fibrin accumulation in some young and diabetic patients implanted with a MICS lens from another manufacturer. So far, no eyes implanted with the CT ASPHINA 409MP have undergone YAG laser capsulotomy. Of course surgical technique, including attention to meticulous cortical cleanup and polishing of the anterior capsule, is also critical for maintaining capsule clarity.”

In addition to the CT ASPHINA 409MP, other aspheric, single-piece ZEISS MICS IOLs are available preloaded with the BLUEMIXS 180 injector. They include the monofocal CT ASPHINA 509MP, the monofocal toric AT TORBI 709MP, the multifocal AT LISA 809MP, and the multifocal toric AT LISA toric 909MP.

Dr Mullaney has no financial interest in Carl Zeiss or its products mentioned here.

Paul Mullaney – paul.mullaney@hse.ie

17 September 2011 XXIX Congress of the ESCRS

CT ASPHINA 409MP IOL – Technical Data

BLUEMIXS 180 injector in OR

“Improved patient comfort has been one of the big benefits I’ve noticed after MICS”

MICS and Toric IOLs – targeting optimum outcomes

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MICS with implantation of a ZEISS MICS toric IOL delivers excellent refractive results that can be attributed to the accuracy of the manufacturer’s advanced calculation algorithm (Z CALC®), the

procedure’s astigmatic neutrality, and the IOL’s rotational stability, according to Michael Goggin MD.

“Cataract surgeons can address pre-existing astigmatism by placing the main incision in the steep meridian. However, this is an imprecise method of astigmatic reduction and not necessary in clear cornea MICS with a toric IOL for which keratometric SIA is essentially nil,” said Dr Goggin, The Queen Elizabeth Hospital, University of Adelaide, South Australian Institute of Ophthalmology, Woodville South, South Australia.

“Surgeons can correct larger amounts of astigmatism with greater accuracy using a toric IOL with an astigmatically neutral incision. The refractive outcome still will depend on proper power selection and intraocular stability of the IOL, but these factors are optimised using ZEISS MICS toric IOL technology.”

Dr Goggin explained that a MICS technique is preferred when implanting toric IOLs because the smaller incision size with a clear corneal technique allows astigmatic neutrality1. However, maintaining this benefit of the MICS incision necessitates use of an IOL that can be delivered through the smaller incision.

“To my knowledge, only Carl Zeiss markets toric IOLs (AT LISA® toric and AT TORBI®) that are capable of insertion through an unenlarged microincision,” he said.

As an alternative, cylinder power of the toric IOL can be selected to correct for any surgically induced astigmatism (SIA), and toric IOL power calculation formulae are designed to correct for SIA. However, this method involves predicting postoperative corneal astigmatism, which is not exact in every case.

“Using a MICS technique and MICS toric IOL that leave the preoperative astigmatism unaltered is clearly preferable,” he said.

Achieving precise refractive outcomes with toric IOL implantation also depends on the accuracy of the power calculation formula, and the ZEISS algorithm is unique in incorporating additional factors that improve its performance. In addition to data on keratometry axis and corneal astigmatism power, Z CALC is the only manufacturer’s toric calculator that includes anterior chamber depth (ACD)/predicted effective lens position and axial length/IOL sphere power to determine IOL corneal plane equivalent cylinder power. The programme also asks surgeons for the source of axial length data (contact or immersion ultrasound or laser interferometry) and the refractive index used by the keratometric measurement device.

In addition, it allows surgeons to modify sphere and cylinder powers according to the targeted residual refraction. With these tools to hand, rational and accurate IOL cylinder power choices can be made for large and small refractive errors.

In a published paper, Dr Goggin and colleagues demonstrated the potential for error in predicted cylinder power using a simpler toric calculator (Alcon AcrySof Toric Calculator). This calculator does not take into account the variation in toric IOL corneal equivalent cylinder power with ACD and IOL sphere power variations2. Comparing the manufacturer’s calculated IOL corneal plane power with a corrected value allowing for sphere power variation, they showed the magnitude of error was small using a toric IOL with sphere and cylinder powers in the standard range. However, there appeared to be significant error with a low sphere, high cylinder toric IOL. In an example based on a toric IOL with +17.0 D sphere and 6 D of IOL plane cylinder, the manufacturer’s stated corneal plane cylinder power could be underestimated by 1.1 D.

In the same paper, Dr Goggin and colleagues reported findings from calculations of corneal plane effective cylinder power of the IOL for 38 eyes implanted with a toric implant (SN60TT, Alcon). The results showed how the prediction of the toric effect was improved taking into account ACD and sphere power of the IOL.

These concepts are illustrated by Dr Goggin’s personal results implanting ZEISS MICS toric IOLs in 52 consecutive eyes. His technique involved coaxial MICS through a 1.8mm temporal clear corneal incision that was stretched slightly after IOL insertion. Mean (SD) incision width after IOL insertion for the 52 eyes was 1.9mm (0.15). Calculations based on pre- and postoperative keratometry data showed the incision was astigmatically neutral; mean (SD) SIA was 0.5 (0.32) D. “As we’ve reported3, keratometric SIA of up to 0.5 D is just ‘noise’, essentially indistinguishable from test-to-test variability of the measurement technique,” Dr Goggin explained.

Mean (SD) distance logMAR UCVA was 0.13 (0.16), which is equivalent to 6/7.5. Among 50 eyes capable of BCVA 6/12 or better, mean (SD) distance logMAR BCVA was -0.02 (0.13), which is equivalent to 6/6.

Dr Goggin has no financial interest in Carl Zeiss or its products mentioned here.

Michael Goggin – michael.goggin@health.sa.gov.au

References1. Kaufmann C, Krishnan A, Landers J, et al. Astigmatic neutrality in biaxial

microincision cataract surgery. J Cataract Refract Surg 2009;35:1555-622. Goggin M, Moore S, Esterman A. Outcome of toric intraocular lens

implantation after adjusting for anterior chamber depth and intraocular lens sphere equivalent power effects. Arch Ophthalmol 2011; 129:998-1003

3. Goggin M, Patel I, Billing K, Esterman A. Variation in surgically induced astigmatism estimation due to test-to-test variations in keratometry. J Cataract Refract Surg 2010;36:1792-3

Take your Practice to a New Level with the ZEISS MICS Platform

Michael Goggin

AT TORBI 709M

“...only Carl Zeiss markets toric IOLs (AT LISA toric and AT TORBI) that are capable of insertion through an unenlarged microincision”

MICS & VISTHESIA for a High Level of Patients’ Satisfaction

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Use of a pain relief ophthalmic viscoelastic device (OVD; VISTHESIA®, Carl Zeiss) during MICS assures intraoperative comfort throughout the procedure and therefore optimises patient satisfaction with the surgical

experience, according to Paul O’Brien MD.Noting that he practises in both private and public hospital

settings, Dr O’Brien said he currently performs about 50 cataract procedures per month. About half of those cases are MICS, and he uses the CT ASPHINA 409MP with the BLUEMIXS 180 injector in all eyes undergoing a MICS procedure.

“About 95 per cent of my cases are done with topical anaesthesia, and I always use VISTHESIA because it maintains comfort for my patients and so for me as well,” said Dr O’Brien, consultant ophthalmologist, Blackrock Clinic, Royal Victoria Eye & Ear Hospital, Dublin, Ireland.

He added that he considers any patient who is not suitable for topical anaesthesia as a candidate for general anaesthesia. However, Dr O’Brien said he was confident recommending VISTHESIA to surgeons who are considering switching from subTenon’s injections to topical anaesthesia.

“Speaking from experience training residents, VISTHESIA has made the transition to MICS with topical anaesthesia relatively easy and straightforward,” he commented.

Each package of VISTHESIA includes two 0.3ml ampoules of VISTHESIA topical containing 0.3 per cent sodium hyaluronate and two per cent lidocaine plus a 0.8ml syringe of VISTHESIA intracameral containing one per cent lidocaine and 1.0 per cent or 1.5 per cent sodium hyaluronate. The sodium hyaluronate in VISTHESIA topical protects and hydrates the cornea, reducing the need for drops during surgery and maintaining corneal clarity, and with the ample volume of VISTHESIA intracameral, there is generally enough product left over after intracameral instillation for use in filling the cartridge of the BLUEMIXS 180 injector.

“It is very rare that I need a second syringe of viscoelastic to finish the case even after using some of the material to fill the IOL cartridge,” he said.

Dr O’Brien noted that he started performing phacoemulsification under topical anaesthesia in 2001 and undertook a study investigating its performance using amethocaine in 100 consecutive patients1. The patients received no sedation or intracameral anaesthesia, and they were asked to rate their pain during sequential stages of the procedure using a visual analog scale of zero to 10.

Phacoemulsification was associated with the highest mean pain score (1.18) followed by IOL insertion (0.84), and none of the mean pain scores for any of the intraoperative stages was significantly higher than the mean reported for instillation of the topical anaesthetic drops (0.47).

“Based on these data, after I administer the topical anaesthetic, I always tell my patients that any subsequent unpleasant sensation is unlikely to be any worse than the little bit of grittiness they just experienced. This information reassures and relaxes them,” commented Dr O’Brien.

Discussing his technique for using VISTHESIA in his topical anaesthesia cases, Dr O’Brien first cautioned that the outer surface of the ampoules of VISTHESIA topical are not sterile, and so the product should not be placed on the instrument tray. He begins by first placing a single drop of 0.5 per cent proxymethacine into both of the patient’s eyes.

Placing this anesthetic in the unoperated eye helps to prevent any discomfort that patients might experience if any povidone-iodine used during the prep splashes into the fellow eye,” Dr O’Brien explained. In his protocol, Dr O’Brien uses povidone-iodine for the scrubbing of the patient’s eye.

VISTHESIA topical is only instilled on the operated eye at the beginning of the surgery. Once the instillation is made, he injects VISTHESIA intracameral, noting that he also places some product over the clear cornea incision as he believes that may reduce the risk of recurrent corneal erosion.

After cataract removal is completed, he uses a wound-assisted IOL insertion technique with the BLUEMIXS 180 injector to deliver the CT ASPHINA 409MP preloaded IOL in his MICS cases.

“I find there is less twisting and turning of the injector using the wound-assisted technique, and even though lens insertion can be one of the more painful surgical steps, no patients have complained about discomfort when I use VISTHESIA,” Dr O’Brien said.

Note: VISTHESIA is not for sale in UK or Portugal.

Dr O’Brien has no financial interest in Carl Zeiss or its products mentioned here.

Paul O’Brien – mrpaulobrien@mac.com

Reference 1. O’Brien OD, Fulcher T, Wallace D, Power W. Patient pain during different

stages of phacoemulsification using topical anesthesia. J Cataract Refract Surg 2001;27:880-3

17 September 2011 XXIX Congress of the ESCRS

Surgery

OVD: VISTHESIA

Paul O’Brien

“...I always use VISTHESIA because it maintains comfort for my patients and so for me as well”

Jorge L Alió

Quality of Life Following Implantation of AT LISA vs. Other Multifocal IOLs

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Results from a prospective, randomised, parallel-group (four arms) study underscore the importance of looking beyond near visual acuity outcomes when assessing the benefits of a multifocal IOL, according to Jorge L Alió MD, PhD.

Global evaluation of the outcomes for the study that compared three multifocal and one monofocal IOLs showed that the AT LISA® 809M (Carl Zeiss), a full diffractive, aspheric multifocal IOL, offered the best profile overall considering impact on visual acuity, functional performance, optical effects and quality of life. The study also showed that although patients implanted with another multifocal IOL benefited with increased near vision function, they failed to achieve improvement in quality of life.

“Quality of life data are complex and can be difficult to interpret because psychology is involved and patient perceptions may be influenced by multiple factors. However, I am convinced this type of information represents the best way to understand if we are helping our cataract surgery patients,” said Dr Alió, professor and chairman of ophthalmology, Instituto Oftalmológico de Alicante, Universidad Miguel Hernandez, Alicante, Spain.

“Although we know that implantation of a multifocal IOL improves near vision, surgeons must realise this technology can also cause photic phenomena, including halos and glare, along with contrast sensitivity loss. As demonstrated in our study and representing a first-time finding, quality of life after multifocal IOL implantation does not always improve when patients gain near vision function if that benefit occurs at the cost of poor quality of vision.”

Dr Alió and colleagues investigated vision-related quality of life after cataract surgery using a validated Spanish version of the 25-item National Eye Institute Visual Function questionnaire (NEI VFQ-25). They enrolled 88 patients undergoing bilateral cataract surgery, ages 49 to 85 years, who were randomly assigned into four equal groups to be implanted with the AT LISA 809M, a spherical monofocal IOL (CT 48S, Carl Zeiss), a refractive multifocal IOL (ReZoom, Abbott Medical Optics), or the +4 D add, apodized hybrid diffractive multifocal IOL (SN6AD3; AcrySof ReSTOR, Alcon). Patients received the same IOL in both eyes.

The quality of life questionnaire along with wavefront aberrometry measurement of high order aberrations (HOA) and tests of near and far visual acuity, reading speed, and contrast sensitivity were performed preoperatively and postoperatively at scheduled visits through six months. The statistical analyses included correlation testing to understand how visual parameters influenced different quality of life items with different IOLs.

Summarising some of the key findings, Dr Alió noted that while correlation analyses showed better near visual acuity and reading acuity were strongly associated with improved perceptions of quality of vision, wellness and general health, patients implanted with the monofocal IOL still benefited with a significant improvement in quality of life. Despite their lack of recovery of near vision, the monofocal IOL patients achieved significant improvements in a variety of tasks, including the ability to find items on a crowded shelf, read street signs and store names, and navigate down stairs or curbs in dim light or at night. In addition, the monofocal IOL was associated with the best contrast sensitivity among the four implants and was best for driving vision.

Results for the multifocal IOLs showed far vision was best with the AT LISA and the results were comparable to those achieved in the monofocal group. Patients implanted with the diffractive AT LISA multifocal IOL and the hybrid apodized ReSTOR multifocal IOL showed improved performance of near tasks, such as reading newspapers or shaving, and improvement in performance of near vision function was better with the two diffractive technologies (AT LISA and ReSTOR) than with the refractive, ReZoom IOL. Reading speed was best in the AT LISA patients followed by patients implanted with the ReSTOR IOL, whose performance was superior to the ReZoom IOL group.

“Correlation analyses for patients implanted with the refractive ReZoom multifocal IOL showed reading improved when HOA RMS is low, but among the multifocal IOLs, the refractive ReZoom induced more HOA than the aspheric ReSTOR and AT LISA. In the ReSTOR group, we also found an inverse relationship between contrast sensitivity and reading difficulty, and contrast sensitivity was better for the AT LISA than with the ReSTOR,” said Dr Alió.

Driving difficulty was also related to contrast sensitivity, and as contrast sensitivity was worse with the ReSTOR IOL than with the AT LISA, the apodized hybrid diffractive ReSTOR multifocal IOL was also associated with more driving difficulties comparing the two diffractive lenses.

Dr Alió concluded with a global evaluation of the IOLs taking into account their impact on visual performance and quality of life. In categories of far vision, near vision, reading speed, contrast sensitivity function and effects on HOA, the AT LISA performed equal to or better than each of the three other IOLs, and it was superior to all of the other implants in improving quality of life. Using an Olympic medal analogy, Dr Alió concluded the AT LISA receives the gold medal.

Dr Alió has no financial interest in Carl Zeiss or its products mentioned here.

Jorge Alió – jlalio@vissum.com

Take your Practice to a New Level with the ZEISS MICS Platform

AT LISA 809M

First Experience with the ZEISS VISALIS 500 Phaco Machine

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The VISALIS 500 is a new state-of-the-art modular phacoemulsification and vitrectomy system that enables safe and efficient surgery, according to Ekkehard Fabian MD.

“There are benefits for operating through a smaller incision, but MICS also places increased demands on the phaco machine for maintaining safety and efficiency. The VISALIS 500 was designed with MICS capabilities in mind, and its innovative features provide surgeons with flexibility benefits while also assuring control,” said Dr Fabian, private practice, AugenCentrum Rosenheim, Germany.

Dr Fabian was involved in the development of the VISALIS 500 platform. Two models are available – the VISALIS S500 for cataract surgery and the VISALIS V500 for combined cataract and/or vitreoretinal surgery.

Highlighting the features of the VISALIS 500 machines for cataract surgery, Dr Fabian mentioned the Surge Security Software that constantly analyses the intraocular environment and uses the information to adjust pump function to maintain high chamber stability. In addition, the VISALIS 500 offers a wide selection of ultrasound emission modes including cold phaco, an advanced fluidics system with dual pump technology, a dual-linear footpedal and an intuitive, user-friendly graphic user interface.

The dual-linear footpedal is hardware that is familiar to those who do retinal surgery or are accustomed to operating with Venturi pump-based units. It has benefits of allowing surgeons to independently control aspiration and phaco power in order to maximise safety and efficiency while also providing ease in changing functions.“Using the footpedal, the surgeon can adjust the operative technique in a variety of ways to maintain safety, such as switching between programs and changing bottle height. By reducing dependence on nursing assistance for changing functions, this technology also increases OR efficiency,” Dr Fabian said.

With the VISALIS 500 dual pump system, surgeons can enjoy on-the-fly switching between Venturi (vacuum-based) and rise-time controlled peristaltic (flow-based) pumps and take advantage of the individual performance characteristics of the two modes according to their surgical needs while also maximising efficiency and safety.

Noting that he had a long-standing preference for a peristaltic pump, Dr Fabian said that since he began using new venturi-type machines, he increasingly integrated the Venturi pump into his surgical technique. This happened also with the VISALIS 500 so that currently, he uses the Venturi mode for the entire procedure in nearly all cases.

Using an intraoperative video, he demonstrated the performance of the VISALIS 500 with the Venturi pump in a MICS case. After good hydrodissection and hydrodelineation, the phaco tip could be maintained in the centre while the nuclear pieces came directly to the tip.“With a Venturi pump, vacuum is created instantly by the pump thus providing immediate followability. Using a peristaltic pump, vacuum is created on occlusion of the phaco tip thus providing better holdability. Today’s dual pump

machines like the VISALIS 500 have this better followability but do not lose the holdability functionality,” he explained.

“The peristaltic pump offers greater anterior chamber stability. However, when using the Venturi pump during fragment removal, there is no need to move the tip to chase the fragments, and that is not possible when operating with a peristaltic pump unless high settings are used,” he said.

Dr Fabian noted that if he is particularly concerned about maintaining anterior chamber stability, such as in an eye with a very narrow anterior chamber, he begins surgery using the peristaltic pump and switches to the Venturi after completing removal of the first two quadrants.“In situations where there is very low volume in the anterior chamber, I want to control vacuum, and I prefer to use the peristaltic pump for increased stability,” he said.

Dr Fabian also observed, that pump choice also reflects individual surgeon preference, and different surgeons may use a variety of different techniques in which they incorporate both pumps into their surgical protocol. For example, one surgeon may start the procedure using the peristaltic pump for chopping and mobilising quadrants and then switch to the Venturi pump for removing the epinucleus and OVD. Another surgeon might also start using the peristaltic pump for sculpting and chopping, but switch to the Venturi pump for segment removal, while a third surgeon might start using the Venturi pump for chopping, switch to the peristaltic pump for fragment removal, and revert to the Venturi pump to finish epinucleus and cortex removal.

With VISALIS 500, surgeons have the possibility to flexibly define their own surgical protocol to optimise the balance between high patient safety and surgery efficiency, Dr Fabian said.

ZEISS surgery solution offers surgeons other innovative products for improving workflow efficiency and surgical results, including FORUM and CALLISTO eye®. FORUM is a software product for digital integration of clinical data from compatible diagnostic instruments. CALLISTO eye offers remote microscope control, integrated HD video documentation, patient data display in the OR and a range of assistance functions, include Z ALIGN®, a video-supported tool for guiding precise intraoperative axis alignment of toric IOLs.

Dr Fabian has no financial interest in Carl Zeiss or its products mentioned here.

Ekkehard Fabian – prof.fabian@augencentrum.de

17 September 2011 XXIX Congress of the ESCRS

Ekkehard Fabian

“I begin surgery with a peristaltic pump and switch to the venturi pump after completing the first two quadrants”

EUROTIMESESC

RS ™

Supported by an unrestricted grant from

Supplement November 2011

17 September 2011xxix Congress of the ESCRS