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Related Videos. Related Content. Study: More than a quarter of older Americans have visual impairment January 17th Commercial real estate and your practice, part two with Colin Carr May 21st Top 5 predictions for ophthalmology in January 16th These phaco platforms also offer pulse, burst, and continuous modes through a tip with a bent design.
The software delivers the alternating torsional and longitudinal pulses after a preset maximum vacuum level is reached, which dramatically reduces tip clogging during emulsification of hard cataracts. There is a need for tip configurations other than the flared or mini-flared designs.
These modifications could lead to increased safety and efficiency of torsional technology in hard cataracts  , . The phaco tip used in torsional phacoemulsification includes a shaft and a cutting edge that has one or two bends. The small-angle rotational movement of the shaft is translated into a horizontal stroke at the tip of the needle. Stroke amplification depends on the angle of the bend near the distal end of the needle and the length of the shaft beyond the bend  , .
Consequently, the geometric configuration of the tip is expected to be an important factor in the procedure's efficiency and surgical outcome. The study protocol was approved by the institutional review board and performed according to the Declaration of Helsinki.
Written informed consent for participation in the study was obtained from each patient. Patients who applied to the clinic in related with diagnosis of age-related cataracts were enrolled in the study.
Exclusion criteria were previous ocular trauma or intraocular surgery, intraocular inflammation, preoperative anterior chamber depth ACD less than 2.
Patients were randomly assigned to surgery groups after they provided informed consent. All patients underwent a complete ophthalmic examination. A Pentacam nucleus staging PNS system was used for nucleus grading  — . Equal numbers of eyes were allocated between the groups for each nucleus density grade.
The 2 tips have similar angles at the aperture of the tips but vary in configuration. In both tips, the outer and inner diameters were 0. The same energy and fluid settings were used to compare the intraoperative performance and postoperative outcomes after microcoaxial torsional phacoemulsification in all patients.
All surgery was performed under topical anesthesia proparacaine hydrochloride 0. Viscoat sodium hyaluronate 3. Trypan blue 0. For endophthalmitis prophylaxis, 0. After surgery, all patients used topical prednisolone acetate 1.
Intraocular pressure was measured using a noncontact applanation tonometer NT, Nidek. In addition, the central corneal thickness CCT was measured using a Pentacam Scheimpflug camera preoperatively and postoperatively 1, 7, and 30d after surgery.
The central endothelial cell density ECD , polymegathism coefficient of variation; CV , and pleomorphism percentage of hexagonal cells were evaluated preoperatively and postoperatively 1, 7, and 30d after surgery using noncontact specular microscopy SP P, Topcon. During each visit, 3 photographs of each cornea were taken and analyzed indepedently by another ophthalmologist.
The mean of the 3 readings was calculated and used as the final reading for each visit. Data normality was assessed using the Shapiro-Wilk test, histograms, and q-q plots.
Differences between groups were tested using the Chi-squared test for categorical variables and independent samples and the t -test for continuous variables. To compare continuous variables in each group over time, one way repeated measure analysis of variance was used followed by a Bonferroni correction.
We enrolled eyes patients and assigned half to the Kelman group and half to the balanced group. Table 1 shows patient characteristics and intraoperative parameters. There were no statistically significant differences in age, sex, cataract density, pupil size, or ACD between the groups.
The respective values were Table 2 shows the nucleus density grades in each group. The mean ECD loss was 8. The percent change in ECD was higher in the balanced group than in the Kelman group throughout the follow up period. Clear ECD measurements could not be obtained in 2 patients in the Kelman group and 8 patients in balanced group 1d postoperatively.
There was a relative decrease in ECD at 1 and 7d postoperative that can be related to the difficulty in measuring ECD caused by greater corneal edema in both groups. No patient suffered intraoperative complications or postoperatively complications, such as synechiae, fibrin formation, or endophthalmitis. PNS: Pentacam nucleus staging. Balanced phaco tips have not been sufficiently available for a prospective comparative study, which is needed to prove the apparent increased performance of these tips over Kelman mini-flared phaco tips.
Phaco tips are designed to both deliver US energy and aspirate material from the lens through its open end. Phaco tips impact efficiency and safety in the phaco procedure through their energy output, holdability, followability, and surge suppression. The choice of phaco tip depends on surgeon preference, which is mainly dependent on the surgical technique i.
Many surgeons prefer a straight tip to the Kelman-style tip in longitudinal phacoemulsification. Traditional Kelman phaco tips are widely used for both longitudinal and torsional phacoemulsification. This tip is excellent for use on the hardest nuclei during traditional longitudinal phacoemulsification. The phaco tip end displacement is dependent on the degree of asymmetry of the tip shaft in torsional phacoemulsification.
A straight tip induces very little phaco tip displacement. As the angle of the bend increases, more movement of the phaco tip cutting end occurs. The amplitude of phaco energy is modified by tip selection. Theoretically, there are 2 ways to enhance the cutting efficiency of a tip.
First is the stroke length; the degree, bent degree Kelman mini-flared tip cuts longer than the degree, bent degree version.
Second is the angulation or bevel; the higher the degree 45 degrees , the better the cutting efficiency  ,  , . The bevel of the phaco tip focuses power in the direction of the bevel. The Kelman tip produces broad powerful cavitation directed away from the angle in the shaft. The cavitational force is concentrated into the nucleus rather than away from it.
This causes the energy to emulsify the nucleus and be absorbed by it. When the bevel is turned away from the nucleus, the cavitational enegy is directed up and away from the nucleus toward the the iris and endothelium.
Flare tips direct cavitation into the opening of the bevel of the tip, minimizing random emission of phaco energy is minimized. The wide opening of the tip makes it easier to minipulate the fragments. The narrow neck of the tip acts as a flow restrictor and reduces the tendency to create surge .
A drawback of Kelman tips, when used for torsional US, is significant tip motion of the shaft which can lead to undesired corneal stroma changes. Heat production, which can lead to wound burn and damage to intraocular structures, is an important disadvantage of emulsification.
A novel balanced phaco tip has been specifically designed for torsional US and has enhanced sideways displacement at the tip end and greatly reduced tip action along the shaft. Its special structure creates less clogging and increases sharpness. The new phaco system also features balanced energy technology that enhances phacoemulsification efficiency through the software.
This system is particularly useful when nuclei are hard, where, thanks to the unique tip motion, the lens material appears to essentially dissolve. By combining the motion of the balanced tip and new fluidics, nuclear material flows to the tip and stays on it so that it virtually disappears as it is emulsified at the shearing plane.
Application of the minimal phaco power intensity necessary for emulsification of the nucleus is desirable. The power intensity is a source of heat, which can result in wound damage. Moreover, excessive cavitational energy is a cause of endothelial cell damage and iris damage with resultant alteration of the blood—aqueous barrier.
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We excluded children, gravida, and patients with other vision-threatening disorders, such as glaucoma, macular edema, and diabetic retinopathy. Patients who did not complete the follow-up program were excluded. Written informed consent for using medical records was obtained from each patient. Surgeries were performed by one experienced ophthalmologist. Intelligent phaco IP mode was used in both groups.
For each pulse, the ratio of longitudinal power and torsional power was 0. A clear corneal incision was made on the steep axis with a 2. A viscoelastic device was used to stabilize the anterior chamber. One-piece hydrophobic intraocular lenses were inserted into capsular bags. Ocular ointment tobramycin 0. After surgery, all patients used topical prednisolone acetate 1. Central corneal thickness CCT , anterior chamber depth ACD and axial length AL were recorded, and intraocular lens diopter was calculated via an OA optical biometer Tomey, Nagoya, Japan at preoperative, 1-day postoperative and 1-month postoperative visits.
The chi-square test was used to analyse the difference in the ratio of sex and eye between the two groups. No patient experienced posterior capsule rupture during the surgery or other severe postoperative complications, such as toxic anterior segment syndrome TASS or endophthalmitis. Stratified analysis was carried out according to the stage of the nucleus and classified patients into soft nuclei stage 2 nucleus and hard nuclei stage 3 and 4 nucleus.
The total CDE 8. Comparison of intraoperative parameters and corneal damage in the soft and hard nucleus subgroups. Torsional and longitudinal energy use in different phaco tip groups.
The total US time, total estimated fluid aspirated, change in CCT and loss rate of ECD at each follow-up visit showed no significant difference among patients with different stages of nuclei.
In addition, bivariate correlation analysis was used to analyse factors associated with corneal edema and the loss rate of ECD. We separately analysed the above parameters among different stages of the nucleus and found the same results among patients with hard nuclei, but patients with soft nuclei showed no statistically significant result. During the cataract phacoemulsification procedure, phaco tips affect energy efficiency and safety through their energy output, holdability, nucleus fragment followability, and surge suppression.
In this study, we focused on the tip efficiency, heat burns and mechanical damage to the cornea caused by phaco tips. Around the incision area, the needle vibrates with the infusion sleeve to produce a frictional thermal effect, resulting in tissue burns. Under the traditional longitudinal US mode, the movement of the needle is along the longitudinal axis and therefore generates more heat at the incision site and lowers the energy efficiency [ 1 ].
Torsional power was first introduced in and was developed to improve efficiency and decrease energy and fluid use [ 4 — 6 ]. The phaco needle for the torsional mode has one or two inclinations at the distal end; when the needle rotates around the longitudinal axis, a larger amplitude is generated at the distal end of the needle. At the near end of the needle around the incision, only a small displacement is generated.
The friction and incision burn are greatly reduced, and the energy efficiency is increased significantly [ 6 ]. The phaco tip applied in torsional phacoemulsification includes a shaft and a cutting edge that has one or two bends. Stroke amplification depends on the angle of the bend near the distal end of the needle and the length of the shaft beyond the bend [ 7 ].
The cutting efficiency is dependent on both the amplitude and the bevel of the tips. The results show that the longitudinal and torsional energy and total CDE used in the IB group are lower than those used in the K group, which confirms their high energy efficiency. This difference was more pronounced in the hard nucleus subgroup and less pronounced in the soft nucleus subgroup.
For hard nucleus phacoemulsification, the phaco needle is often blocked, at which time the phaco energy is continuously released but no nucleus material is crushed, and the energy efficiency is significantly reduced. The phaco platform offers pulse, burst, and continuous modes. All the longitudinal energy used in this study came from pulses in IP mode.
More blocking occurrences and a longer blocking time during phacoemulsification will trigger more longitudinal energy and a longer use time. The results show that the CLE of Group K is statistically higher than that of Group IB, indicating that the balanced needle is less likely to cause obstruction due to its large swing, suggesting that the larger amplitude of the balanced needle is more efficient for the hard nucleus.
This advantage is not significant in the soft nucleus subgroup, as soft nucleus US rarely causes needle blocking and longitudinal energy is rarely triggered. The increase in CCT on the first postoperative day and corneal endothelial loss rate at 3 months are indicators of short-term and long-term corneal damage from cataract surgery.
The damage mainly comes from the mechanical damage caused by the turbulence of the aqueous humor, the impact of the nuclear fragment on the corneal endothelium and the incision burns caused by phaco needle vibration. Tissue burns can be avoided by decreasing heat production and sufficient infusion in the irrigation sleeve, which can cool down the needle.
The Kelman needle is paired with a standard infusion sleeve that matches for a 3. Asmaller incision and irrigation sleeve will theoretically limit the infusion flow. Previous studies have included balanced needles with an active fluidics infusion system to maintain sufficient infusion and IOP [ 10 , 11 ].
To our knowledge, a comparative study of balanced needles with gravity perfusion systems with Kelman needles under the same system has not been reported. The results of this study showed no significant difference in either US time and estimated fluid volume or the corneal endothelium loss rate at 3 months postoperatively between the two groups, implying the noninferiority of the balanced needle compared with the Kelman needle in terms of intraocular tissue damage, which also indicates that the ultra-perfusion sleeve can provide sufficient perfusion flow within a 2.
According to the two-variable correlation analysis in the study, postoperative corneal edema and endothelial cell loss were positively correlated with the total energy used in surgery, as well as longitudinal and torsional energy use. Lower energy use may create less frictional heat at the incision site, which reduces incision burns and causes less mechanical tissue damage.
In this study, lower CCT changes in the IB group on the first postoperative day were observed without statistical significance. Further analysis of the original data reveals that when the nucleus is hard and more energy is used, the standard deviation of CCT changes increases considerably, which will affect the statistical results. Increasing the sample size will help to achieve a more convincing result. ACD should also be considered when evaluating corneal damage. Jensen et al.
A balanced tip is more likely to present higher efficiency and more corneal damage, as shown in previous literature [ 8 , 13 , 14 ]. We expect comparable corneal damage in the two groups under such energy settings, which is in accordance with our results. Postoperative CCT and ECD loss are affected not only by the efficacy of the phaco tips but also by the corneal incision size and the perfusion sleeves, which are different in each group.
The results of the study showed total differences between the two group settings. The corneal incision size and the perfusion sleeve effects were not analysed. A larger sample size will help to reach more convincing conclusions. In summary, a balanced phaco needle is an energy-efficient needle covered by an ultra-perfusion sleeve within a 2. The advantages of the needle are more pronounced in hard nuclear cataracts, and needle blocking occurs less frequently.
YXS was responsible for designing the protocol, administrative support of the study, provision of study materials and patients and manuscript writing.
CR was responsible for designing the protocol, provision of study materials or patients and collection and assembly of data. HQX was responsible for extracting and analysing the data, interpreting the results and creating the tables and figures. LG was responsible for administrative support of the study and patient follow-up. DDS was responsible for following up the patients and collecting the data. The author s read and approved the final manuscript. This retrospective cohort study was approved by the ethical committee of Peking University Third Hospital M Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yan-Xiu Sun and Rong Cao contributed equally to this work. Zacharias J. Comparative motion profile characterization of the miniflared and balanced phacoemulsification tips. Narendran N, et al. The Cataract National Dataset electronic multicentre audit of 55 operations: Risk stratification for posterior capsule rupture and vitreous loss. Salowi MA, et al. Br J Ophthalmol.
Shumway C. Utility of a novel hybrid phacoemulsification tip to prevent posterior capsule rupture. Thermal characterization of phacoemulsification probes operated in axial and torsional modes. Laboratory assessment of thermal characteristics of three phacoemulsification tip designs operated using torsional ultrasound.
Clin Ophthalmol. Noguchi S, et al. Difference in torsional phacoemulsification oscillation between a balanced tip and a mini tip using an ultra-high-speed video camera. Phacoemulsifier occlusion break surge volume reduction. Aqueous volume loss associated with occlusion break surge in phacoemulsifiers from 4 different manufacturers. Effect of IOP based infusion system with and without balanced phacotip on cumulative dissipated energy and estimated fluid usage in comparison to gravity fed infusion in torsional phacoemulsification.
Eye Vis Lond. Vasavada AR, et al. Comparison of torsional and microburst longitudinal phacoemulsification: A prospective, randomized, masked clinical trial. Ophthalmic Surg Lasers Imaging. Experimental anterior chamber maintenance in active versus passive phacoemulsification fluidics systems. Mechanical model of human eye compliance for volumetric occlusion break surge measurements. Comparison of occlusion break responses and vacuum rise times of phacoemulsification systems.
BMC Ophthalmol. Check if a local MyAlcon page for your country to access country product information. This platform is intended to provide general product information for education and illustration purposes. It is not intended to provide information to the general public or medical advice.
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