1. THE OUTCOMES OF MICS WITH CRUISE CONTROL SYSTEM VS MICS WITH WHITESTAR ICE AND CASE SETTINGS IN HARD CATARACTS HELVACIOGLU Firat, MD, SENCAN Sadik, MD, OGUZHAN Hasan, MD, YETER Celal, MD Bakirkoy Education And Research Hospital Department Of Ophthalmology, Istanbul TURKEY The authors have no financial interest in the subect matter of this poster

2. PURPOSE To compare the safety and efficacy of Whitestar ICE and CASE settings with cruise control system in bimanual MICS. Micro forceps Duet system Divide & Conquer

3. METHODS Between January 2006 and March 2008, MICS (G1) was performed in 20 eyes of 18 patients by using the AMO- Sovereign Whitestar surgical system with the aid of cruise control system. MICS (G2) was performed in 20 eyes of 17 patients by using the AMO-Sovereign Whitestar surgical system with ICE and CASE settings. Patients were chosen according to their nuclei hardness (grade3-4). Patients were examined for: intraoperative complications, intraoperative complications, Mean phaco time Mean phaco time Total phaco % Total phaco % EPT EPT % endothelial cell loss % endothelial cell loss postoperative corneal edema and postoperative corneal edema and anterior chamber reactions. anterior chamber reactions.

4. METHODS Phaco 1 – Grooving Aspiration Vaccum WhiteStar Aspiration Vaccum WhiteStar Unoccluded & 22 cc/min. 50 mmHg 30%-50% Occluded Linear Panel Linear Phaco 2 – Chopping Aspiration Vaccum WhiteStar Aspiration Vaccum WhiteStar Unoccluded & 28 cc/min. 350 mmHg 30%-50% Occluded Linear Linear Linear C/F (33%) Operation cycle used in both groups ICE 1 ms/constant kick CASE vaccum 200 mmHG

5. ENERGY PARAMETERS AND ENDOTHELIAL CELL LOSSES MICS + CRUISE CONTROL Mean EPT (seconds): 3.75 (SD 1.18) 3.75 (SD 1.18) Mean US time (min.): 1.45 (SD 0.18) 1.45 (SD 0.18) Mean total phaco %: 5.1 (SD 1.3) 5.1 (SD 1.3) MICS + ICE&CASE Mean EPT (seconds): 3.22 (SD 1.38) 3.22 (SD 1.38) Mean US time (min.): 1.24 (SD 0.22) 1.24 (SD 0.22) Mean total phaco %: 4.8 (SD 1.1) 4.8 (SD 1.1) Group 2 mean end. preoppostop Loss % 23762253 5.2 % Group 1 mean end. preoppostop Loss % 23222184 5.7 %

6. There was not any complication affecting the visual outcome in both groups. There was not any statistical significance between the groups in the values of the; endothelial cell loss endothelial cell loss the EPT the EPT the rate of intraoperative complications, the rate of intraoperative complications, the grade of postoperative corneal edema and anterior chamber reactions the grade of postoperative corneal edema and anterior chamber reactions No corneal burn was seen and both types of operations were performed safely and efficiently in hard cataracts. RESULTS

7. POSTOPERATIVE CORNEAL EDEMA AND ANTERIOR CHAMBER REACTIONS Postoperative Corneal Edema Postoperative Anterior Chamber Reactions

8. DISCUSSION MICS has many advantages; Switch incisions, create space and manipulate lens fragments with irrigation, Switch incisions, create space and manipulate lens fragments with irrigation, Irrigate without pushing the lens fragments away from the aspiration tip, Irrigate without pushing the lens fragments away from the aspiration tip, Increase safety, less turbulent and more stable anterior chamber, Increase safety, less turbulent and more stable anterior chamber, Improved control on hydrodissection and capsulorhexsis, Improved control on hydrodissection and capsulorhexsis, less risk of leakage, theoretically reduced risk of endophthalmitis, less risk of leakage, theoretically reduced risk of endophthalmitis, accelerate visual rehabilitation, astigmatically neutral ( <1.5 mm) accelerate visual rehabilitation, astigmatically neutral ( <1.5 mm) Main limiting factors (1); The limits in IOL technology (this field continues to grow rapidly), The limits in IOL technology (this field continues to grow rapidly), the narrow lumens of the irrigating choppers that limits the max vacuum levels (Both ICE and CASE systems and Cruise Control system allows us to use higher vacuum settings by controlling post occlusion surges 2) the narrow lumens of the irrigating choppers that limits the max vacuum levels (Both ICE and CASE systems and Cruise Control system allows us to use higher vacuum settings by controlling post occlusion surges 2) the increase risk of corneal burn (3), (The risk is low if the phaco device and the settings were appropriate for this surgery) the increase risk of corneal burn (3), (The risk is low if the phaco device and the settings were appropriate for this surgery) The safety and efficacy of bimanual MICS increases by the aid of cruise control system which provides higher vacuum, less US energy and less turbulance. 1.Fine H, Hoffman RS, Packer M. Optimizing refractive lens exchange with bimanual microincisiion phacoemulsification. J Cataract Refractive Surg 2004; 30:550-554 2.Chang D.F. 400 mmHg high vacuum bimanual phaco attainable with Staar Cruise Control device. J Cataract Refractive Surg 2004; 30:932-933 3.William Soscia et all. Microphacoemulsification with Whitestar, A wound temperature study. J Cataract Refractive Surg 2002; 28:1044-1046

9. DISCUSSION The Cruise Control was designed to reduce postocclusion surge with standard phaco instrumentation. However, its ideal application is with bimanual phaco, in which more limited irrigation inflow has otherwise prevented the safe use of high vacuum settings from surge. The device consists of a 2 cm flow-restricting segment with a 0.3 mm internal lumen. It is positioned behind a mesh filter that traps emulsified nuclear material before it can clog the flow restrictor. 1.Chang DF. Correspondance. 400 mm Hg High-Vacuum Bimanual Phaco Attainable with the Staar Cruise Control Device. 2004;30(4):932-933  400 mm Hg high-vacuum bimanual phaco attainable with this device. (1)  Up to 300 mm Hg vacuum was used in G 1, the operations performed safely without any complication.

10. WHITESTAR ICE AND CASE TECHNOLOGY Kick seperates nucleus from phaco tip and creates a microspace thus increase cavitation CASE is an occlusion mode technology which senses occlusion breaks, reverses the pumping system within 26 miliseconds thus decreases the risk of surge and anterior cahmber insatbility in high vaccum settings DISCUSSION

11. DISCUSSION In recent years, damage to corneal endothelial cells during cataract extraction has been minimized as a result of better instrumentation, newer viscoelastic materials, and improved surgical techniques which aims to reduce phaco time (1). Studies report endothelial cell loss rates from 4% to 15% after phacoemulsification by experienced surgeons (2,3) The 5.7% and 5.2% of mean endothelial cell losses demonstrated the safety of the surgeries performed in hard cataracts. Both systems give us to ability to perform MICS in hard cataracts 1.Holzer MP, Tetz MR, Auffarth GU, et al. Effect of Healon5 and 4 other viscoelastic substances on intraocular pressure and endothelium after cataract surgery. J Cataract Refract Surg. 2001;27:213-218 2.Kosrirukvongs P, Slade SG, Berkeley RG. Corneal endothelial changes after divide and conquer versus chip and flip phacoemulsification. J Cataract Refract Surg. 1997;23:1006-1012 3.Zetterström C, Laurell C-G. Comparison of endothelial cell loss and phacoemulsification energy during endocapsular phacoemulsification surgery. J Cataract Refract Surg. 1995;21:55-58

12. CONCLUSIONS The Cruise Control device gives us the ability to perform MICS with higher vacuum settings without affecting the safety of the operations. Modern phaco systems give us the ability to use sleeveless, bare phaco tips from very small corneal incisions. By the aid of ICE and CASE settings, it is possible to use higher vacuum settings and less US power without cruise control system.