Eyeworld

40 | EYEWORLD | SEPTEMBER 2019 ATARACT C YES CONNECT New instrumentation for cataract surgery continued on page 42 T here are a number of new technologies making their mark in cataract surgery. Among them are Zepto (Mynosys), miLOOP (Carl Zeiss Meditec), and the Light Adjustable Lens (RxSight). Kevin Waltz, MD, Susan MacDonald, MD, and Bennett Walton, MD, offered their insights on these technologies. Automating the capsulotomy Creating a continuous curvilinear capsulorhexis manually is one of the most fundamental as- pects of cataract surgery training, but there are a number of technologies that are automating this part of the procedure. The femtosecond laser is one example, but a more recently ap- proved device with a smaller footprint is Zepto (FDA approved in 2017), which consists of a collapsible nitinol ring, a silicone suction cup, and an energy source that heats the nitinol ring and water molecules that are trapped in the suction cup, creating the capsulotomy. CAPSULaser (Excel-Lens) is another automated capsulotomy device, but it is not yet approved by the U.S. FDA. Dr. Waltz has been working with Zepto since 2015, initially as the principal investiga- tor for the device's first in-human trials in El Salvador. While the main purpose of Zepto is to create consistently sized, perfectly round, and reproducible capsulotomies centered on the visual axis, Dr. Waltz said the device provides a number of advantages beyond its original intent. One that's been documented in peer-re- viewed literature is improved capsule strength. As Dr. Waltz said and as scanning electron micrographs show, Zepto creates a slight upturn in the capsular edge at the cut. Capsule edge tear strength from capsulotomies created with Zepto, femto, and manually have been com- pared, and Zepto-created were found signifi- cantly more resistant to tearing. 1 Dr. Waltz said there is early, unconfirmed, signals suggesting Zepto decreases the burden of epithelial cells remaining in the eye after sur- gery. He said long-term monitoring of patients in El Salvador, where you would expect to see a higher rate of PCO, show a low rate of PCO with Zepto. Dr. Waltz hypothesized that the vacuum release of the capsulotomy helps the surgeon do a thorough and effective hydrodis- section that appears to "change the biology of the healing." Compared to the femtosecond laser, Zepto has advantages in price and footprint. Cortex removal, Dr. Waltz said, is easier with Zepto- created capsulotomies, while it's harder with femtosecond laser-created capsulotomies. Ad- vantages of the laser systems, Dr. Waltz noted, are that some are able to match the visual axis to markers on the capsule, and they can make astigmatic cuts. But the femtosecond laser and Zepto are not mutually exclusive, Dr. Waltz said, noting that some surgeons who offer femto laser-as- sisted cataract surgery have found Zepto to be an attractive alternative upgrade for patients by Liz Hillman EyeWorld Senior Staff Writer This month's YES Connect column focuses on new tech- nologies in cataract surgery. In training, everything is new at first, but residents and fellows have the advan- tage of working with an experienced surgeon to guide them as they learn. Once in practice, though, there is both a time commitment to learn- ing a new technique as well as a financial commitment in purchasing the technol- ogy. This month's column explores the advantages and disadvantages of three new promising tools in cataract surgery that young surgeons may consider incorporating into their practices. —Julie Schallhorn, MD, YES Connect Co-editor 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. Source: Russell Swan, MD

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