Eyeworld

EW CATARACT 44 October 2017 by Liz Hillman EyeWorld Staff Writer cataract missions in developing countries where he witnessed how surgeons there, even if they have a phaco machine, often perform manual extracapsular cataract sur- gery due to the density of the lenses encountered. "Even if they have phaco, they push it to the side; 95% of surgeries are done manually," Dr. Ianchulev said. "There is a reason doctors are doing that even if you give them the technology. Part of the reason is phaco is not good for those hard cat- aracts. It's complicated … and you end up using a lot more energy." This, coupled with his work on the CyPass (Alcon, Fort Worth, Texas) as a micro interventional technology for glaucoma, led him to think about developing a way to fragment the lens endocapsularly without energy through a small incision. "This can fragment any cata- ract, any density," he said. The loop results in centripetal fragmentation with mechanical force from the outside inward, whereas traditional phaco fragmentation goes from the inside outward. While Dr. Ianchulev demon- strated at the ASCRS•ASOA Sym- posium & Congress that miLOOP can be useful for both soft and hard cataracts, Dr. Newsom said he finds it most useful for the latter. Soft cataracts, he explained, require such a small amount of phaco energy already that he doesn't see much of a difference in using miLOOP there. Hard cataracts, how- ever, could take up to 60 seconds of phaco energy, he said. Dr. Ianchulev said there is a 40% reduction in phaco energy, on average, with miLOOP. According to Iantech's website, a not-yet-published randomized controlled trial was conducted to compare the clinical outcomes and surgical efficiency of traditional phaco surgery with "low energy en- docapsular phaco." According to the company, the miLOOP group saw "statistically improved surgical per- formance with significant reduction in burst phaco energy and fluidics to the eye." The miLOOP is not the only device capable of phaco-less lens to provide feedback about the device during its development, called it something that "needs to be in ev- ery single operating room." "This is making those diffi- cult cases much easier to do," Dr. Newsom said, adding later that its learning curve is next to nothing. "It has the potential to make that surgical skill that we have to teach with phaco go away. Learning how to chop, learning how to divide and conquer, learning how to have all these fancy techniques to disas- semble the lens—those may become moot skills. Why would you take the time to develop those skills over thousands of cases when you have this instrument available?" he asked. "I don't want to say that it's going to eliminate phaco, but it's going to take the learning curve of phaco from where I have done thousands of cataracts that put me at a certain level to where I can do 20 and I'm fine." Dr. Ianchulev said the miLOOP is an extension of micro interven- tional technology into cataract surgery—similar to how MIGS ap- plied stent technology in glaucoma. He appreciated the need for such technology from his humanitarian section plane, looped around the lens, and upon retraction, full-thick- ness lens fragmentation is achieved, cutting it in half. This process could be repeated several times, fragment- ing the cataract into multiple pieces that could be aspirated out or even removed manually. The miLOOP is an FDA-registered 510K device that has been on backorder since its announcement at the ASCRS•ASOA Symposium & Congress. "The problem is, we have so much demand that the company cannot make it fast enough," Dr. Ianchulev told EyeWorld. Richard Lindstrom, MD, adjunct professor emeritus, Depart- ment of Ophthalmology, University of Minnesota, and Minnesota Eye Consultants, Minneapolis, said it has gotten "a very warm welcome both with the sophisticated phacoemulsi- fication surgeon and with the small incision extracapsular surgeon in emerging countries who would like to reduce trauma and reduce the size of their incisions." "Cataract surgery can be a cinch with the miLOOP," Dr. Ianchulev said. Hunter Newsom, MD, Newsom Eye, Tampa, Florida, who was asked Could be a move toward a phaco-free future I t's been 50 years since the in- vention of phacoemulsification by Charles D. Kelman, MD, which has established itself as the gold standard for cataract surgery. While there have been doz- ens of improvements to the proce- dure and its technique, how the lens is broken up with ultrasonic energy has largely remained the same, as have some of the drawbacks that go hand-in-hand with that energy. At the 2017 ASCRS•ASOA Sym- posium & Congress, Sean Ianchulev, MD, MPH, professor of ophthalmol- ogy, New York Eye and Ear Infirmary, Icahn School of Medicine, Mount Sinai, New York, introduced a device that could radically change the pro- cedure. Instead of delivering phaco energy to chop up and dissect a lens for aspiration out of the eye, Dr. Ian- chulev described a pen-like handheld device with a super elastic, memory- shaped nitinol loop at the end. The micro interventional loop device, called miLOOP (Iantech, Reno, Nevada), is inserted through a small incision, unfolded in the hydrodis- New device promises mechanical nuclear fragmentation to reduce phaco energy miLoop performs manual dissection of a cataract through a small incision, resulting in less phaco energy delivered to the eye. Source: William Wiley, MD continued on page 46

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