Eyeworld

FEB 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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80 80 EW REFRACTIVE SURGERY February 2012 Device focus Diamonds are a [surgeon's] best friend by Michelle Dalton EyeWorld Contributing Editor Or are they? When it comes to cataract keratomes, diamonds aren't always the first choice W hen it comes to the topic of cataract knives, surgeons are steadfast in their alle- giances. Some prefer metal blades, others prefer dia- monds, and still others prefer a com- bination depending on which part of the surgery is being performed. EyeWorld spoke to some leading cataract surgeons and developers to find out which blades they use and why. Metal keratomes A distinct advantage of disposable metal blades are their "tactile feed- back," said Preston H. Blomquist, M.D., associate professor, vice chair of education, and residency program director, University of Texas South- western Medical Center, Dallas. "I like the slight resistance a metal blade has cutting through tissue as opposed to the diamond blade." He believes metal blades are more bene- ficial for residents because he can help correct technique issues intra- operatively (such as identifying/cor- recting when residents are holding the blade at an angle rather than horizontally). "Since the diamond blade cuts so effortlessly, the resident may complete the incision before I can get a verbal admonishment out," he said. Another consideration is where the OR is located—in his public county hospital environment, "it's Additional reading, as recommended by Dr. Blomquist: 1. Dubey R, Brettell DJ, Coroneo MT, Francis IC. Obviating endophthalmitis after cataract surgery: excellent wound closure is the key. Arch Ophthalmol 2011; 129:1504-1505. 2. Francis IC, Roufas A, Figueira EC, Pandya VB, Bhardwaj G, Chui J. Endoph- thalmitis following cataract surgery: the sucking corneal wound. J Cataract Refract Surg 2009;35:1643-1645. difficult to keep diamond blades sharp." Bonnie An Henderson, M.D., assistant clinical professor of oph- thalmology, Harvard Medical School, Boston, also prefers dispos- able blades because the surgery cen- ter is high volume and supports numerous surgeons. "I like the precision and exqui- site control of a diamond blade, but the additional care is too difficult to monitor," she said. She alternates between two OR rooms and uses ei- ther a 2.2 mm or 2.8 mm keratome depending on the phaco machine. "I do, however, use a diamond blade for astigmatism-correcting in- cisions," she said. For Richard Mackool, M.D., Mackool Eye Institute, Astoria, N.Y., disposable blades have significant advantages over diamond blades. "Incision size changes from time to time, and even from case to case, and a diamond blade can become outdated," he said. "Diamond blades are quite unforgiving, and it's diffi- cult to 'redirect' the blade if it gets off track. They also break very easily and that can become expensive." Diamond keratomes On the other side of the debate, Randall J. Olson, M.D., John A. Moran Eye Center, University of Utah, Salt Lake City, uses only dia- mond blades. "For my main incision, I use the Mastel (Rapid City, S.D.) President blade, and my sideport blade is also a 1.0 mm diamond from Mastel," he said. "I have used steel blades and would have no problem with them. They are not as sharp but are very consistent and do give more tactile feedback." Also, while diamond blades are "very precise and effortless," steel blades are "much less likely to cut out on either side," he said. Lisa B. Arbisser, M.D., clinical adjunct associate professor, John A. Moran Eye Center, uses a diamond blade she helped design, the Arbisser-Fine Triamond diamond trapezoidal blade (Mastel). "Because it is 0.3 mm at the tip increasing to 1.0 mm, I can make an incision of any size," she said. She uses the blade for her paracentesis as well as her main incision (presently measur- ing 2.4 mm in chord length). Two views of the Arbisser-Fine Triamond diamond trapezoidal blade Source: Lisa B. Arbisser, M.D. "The incision measures close to a standard 2.2 mm keratome since the blade is so thin," she said. "I don't hydrate the stroma so much as irrigate it to ensure there is no debris between the lips of the incision to get it closed. I look for a dry gutter with normal to high normal pres- sure." Likewise, Farrell C. Tyson II, M.D., private practice, Cape Coral, Fla., uses diamond blades exclusively "as I own my own ASC and they are more cost-effective," he said, adding he finds diamond blades "to be eas- ier to penetrate the cornea and pro- vide a cleaner wound. In the past I have used some steel blades that left behind metallic particles in the wound." Combined keratome use Combination blade use is not as common, but Steven G. Safran, M.D., private practice, Lawrenceville, N.J., uses a 2.75 or 2.85 mm metal blade for the main cataract incision and a trifacet dia- mond blade (Accutome, Malvern, Pa.) for the paracentesis and "to make groove incisions and lamellar dissections when performing scleral work." His preference is for blades that are beveled on only one side, with the other side flat, "not the newer microthin blades that are beveled on both sides." Dr. Safran's technique is to use his finger as a counter pressure "as I make my incision and pull up on

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