Eyeworld

63 EW FEATURE Dr. Kretz uses Zepto in patients with severe zonular disorders where he needs additional zonular support and in patients where he expects phimosis, such as young children and those with retinitis pigmentosa. Surgeons can use Zepto on patients with small pupils, white cataracts, and other complicated cases, with the only limitation being an ante- rior chamber depth of at least 1.8 millimeters, he said. Zepto offers a significant ad- vantage when operating on white cataracts, according to Drs. Waltz and Swan. "Here is the classic situation that you worry about with a white cataract: You're worried about it being under some tension so when The Zepto handpiece has a collapsible capsulotomy tip whose main component is a low profile, transparent silicone suction cup that houses a thin-walled nitinol capsulotomy ring. you put a little hole in it, you might get an extension, and you get an Ar- gentinian flag sign," Dr. Waltz said. "With Zepto, it cuts the 360-degree hole simultaneously, so you get in- stantaneous release of the pressure. You don't have to worry about an Argentinian flag sign." "Because you have a 4-millisec- ond capsulotomy, I am even more comfortable [with Zepto] than with the femto, and the strength and stability of the capsule with it is fan- tastic," Dr. Swan said. "I think that it's a game changer there." Zepto can even provide bene- fits for pediatric cataracts. Because pediatric capsules are much more elastic and behave differently during surgery, creating the capsulotomy is AT A GLANCE • The Zepto system creates a perfectly circular, centered capsulotomy in 4 milliseconds. • The device is useful for complicated cases, such as white cataracts and pediatric patients. • The device preserves the visual axis during surgery, allowing the surgeon to customize placement of the cap- sulotomy. September 2018 • Products that could change how you practice continued on page 65 difficult. But Zepto has the potential to make these surgeries faster, easier, and safer for the patient, according to David Sretavan, MD, co-founder of Mynosys. "We've had a lot of pediatric cataract surgeons contact us because they see this as a useful tool to help them create that capsulotomy," he said. "We'd like to address that. It re- quires a bit of engineering in terms of coming up with a device that will create a capsulotomy of the appro- priate size, but that is something that the company intends to do fairly soon." One unexpected benefit of the device is that because the silicone suction cup is transparent, Zep- to allows the surgeon to preserve visual axis information typically lost during surgery. "Everyone has his or her unique visual axis, and Zepto allows the surgeon to customize the placement of the capsulotomy to fit the visual axis of that particular patient," Dr. Sretavan said. "That's a benefit of a Zepto capsulotomy, and it feeds into the concept that Zepto is much more than just a capsuloto- my device; it has benefits through many different important stages of cataract surgery." Advantages to the surgeon By making complex cases routine and routine cases more consistent, Zepto allows seasoned ophthalmolo- gists to extend their surgical careers, according to Dr. Waltz. "One of the things that caus- es people to retire from surgery is inability or [discomfort] achieving a consistent capsulotomy," Dr. Waltz said. "We've had a number of ma- ture surgeons say, 'This is important for me because I'm going to be able to operate for years longer because now I can be assured of my capsulo- tomy; the rest of it I'm comfortable with, but I was becoming uncom- fortable with my capsulotomy.'" Dr. Swan sees it as a "definite go-to" for any refractive or premium case. "I think a well-centered capsu- lotomy that has great optic overlap is important to give the best refrac- tive outcome, and I think it's a nice add-on for those cases," he said. Many surgeons have noticed that after creating a Zepto capsulot- omy, it's as if the hydrodissection is almost or fully complete, and they need to do very little in terms of fluid injection to get the lens to spin and rotate freely, according to Dr. Sretavan. Zepto requires suction to make the capsulotomy, and when the capsulotomy is complete, that suction is released by reintroducing OVD and balanced salt solution into the capsular bag, which creates a 360-degree enclosed hydrodissection effect as part of the device's removal. "That has been a benefit that surgeons have told us that they're seeing, and Mynosys will be opti- mizing that into Zepto so that more surgeons will have that affect and it will become a reliable result from a Zepto capsulotomy," Dr. Sretavan said. The effortless hydrodissection improves healing, which helps pre- vent postoperative posterior capsule opacification (PCO), according to Dr. Kretz. In addition, the micro- pulse vibrations that create the cap- sulotomy help loosen epithelial cells from the capsule, which also helps prevent PCO after surgery, he said. Zepto vs. femto The surgeons agree that Zepto and femto are complementary devices for creating automated capsuloto- mies. While there is overlap be- tween the two, each technology has particular advantages. The femtosec- ond laser can soften and fragment the nucleus and make incisions, which Zepto cannot do. But Zepto " We wanted to make sure that not only the highly skilled surgeons could use it, but the average surgeon could use it. " —David Sretavan, MD

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