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Intrepid FMS
Innovations in the Infiniti Vision System, the Intrepid FMS (Fluid Management System)
April 18, 2008 by Vantage Technology
The Infiniti Vision System (manufactured by Alcon Laboratories, Inc) has again excited the community of Cataract surgeons worldwide. The revolutionary Torsional technology has brought forth a rejuvenation of innovation in surgical techniques and superior patient outcomes. The latest addition to the Alcon product line is the Intrepid Micro-Coaxial System. One of its primary and most essential components is the Intrepid FMS (Fluid Management System). This system has been specifically designed to enhance fluidics in the surgical environment, especially for the surgeons who prefer the incision widths of 2.4mm or smaller. The rigid, low compliance tubing allows for a better and safer response even at higher flow rates and vacuum settings. It creates a greater level of chamber stability, provides better control, and allows for customization to individual patient needs. Overall, the Intrepid FMS (Fluid Management System) brings a new and exciting aspect to an already innovative approach to Phacoemulsification.
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Intrepid FMS allows me to use higher vacuum levels with lower bottle heights.Intrepid FMS limits iris movement following occlusion break in my Flomax patients.
Before any nuclear pieces enter the tip during phaco, a steady state of fluid movement exists, flowing out the infusion sleeve and going into the phaco aspiration port. As the tip begins to occlude with nuclear material, the pressure begins to rise in the anterior chamber and cassette tubing. When the tip becomes occluded, the vacuum level in the tubing will quickly rise until it reaches the maximum level. Once the occluding piece is emulsified, there will be a sudden drop in ocular pressure within the anterior chamber as fluid in the eye rushes into the aspiration port to satisfy the high vacuum that was created in the tubing. This is known as post-occlusion surge.Any significant post-occlusion surge is a dangerous situation. The anterior chamber shallows, and the iris moves toward the phaco tip. The suddenness of such an event may not allow the surgeon time to prevent posterior capsule rupture or significant iris trauma. Post-occlusion surge is less significant today with modern phaco technologies that incorporate newer fluidic management strategies, but it still occurs to varying degrees with all phaco platforms.Micro-Incisional Phaco Limits Irrigation With standard-size incisions ( 2.5 mm and above)—even with high-infusion sleeves— we still can see some small amounts of surge. But contro 戀鞋癖lling surge is more important with micro-incisional phaco because small incisions restrict the amount of irrigation that can enter into the eye even if the balanced salt solution (BSS) bottle is raised very high.Raising the BSS bottle higher is not innocuous. One downside of raising the BSS bottle is a concomitant increase of pressure in the eye. Another more potentially damaging side effect is an increase in anterior chamber turbulence from the high-pressure stream coming into eye. High turbulence can induce miosis during surgery and can adversely affect the corneal endothelium.Another strategy to combat post occlusion surge during microincisional phaco is lowering the fluidic settings by decreasing vacuum levels and aspiration flow rates to decrease the amount of post-occlusion surge.The problem with this strategy is that you end up decreasing your surgical efficiency as a consequence.Less Compliant Design The Intrepid Fluid Management System, or Intrepid FMS, (Alcon, Fort Worth , Texas ) is a less compliant (more rigid) tubing system than even the existing Infiniti FMS. The less compliance you have in a system, the less post-occlusion surge you’ll have. Lab tests demonstrate that the volume of fluid that rushes into the tip during occlusion breaks (surge) was markedly reduced with the Intrepid FMS. To determine if clinical experience would match the lab results, I compared, in masked fashion, chamber stability to the standard FMS to stability with the Intrepid FMS in approximately 100 patients. I used a rating scale from one to 10, on which a score of six or less represented some element of significant surge and a score of 10 was not possible to achieve with any fluidic system within a compliant chamber of the eye. A rating of 10 meant that nothing moved, that the surgeon would not be able to see any iris fluctuation or any shallowing of the chamber or posterior capsule movement. A rating of eight meant that I could barely see iris movement or posterior capsule movement and that the safety margins during phaco were excellent. With the Intrepid FMS, we had twice as many ratings of eight than with the existing system.The Importance of Confidence with Micro-Coaxial As I moved to torsional micro-coaxial phaco, surgery felt no different than with a 3.2-mm incision, so the transition was nearly seamless. Now, I no longer make an incision larger than 2.2 mm yet I still have great confidence in ocular stability using the Intrepid FMS. With the Intrepid FMS, I found that the posterior capsule routinely doesn’t normally budge, even when you’re working on the last quadrant. When aspirating that quadrant, even if I’ve reached vacuum levels at or near 400 mm Hg, the posterior facebook capsule is quite stable even without raising the BSS bottle. The Intrepid cassette has stiffer aspiration tubing, so some ergonomic compromise is noticeable, mostly during I%26A, when the handpiece typically is moved, twisted, and rotated more than during phaco.I can evaluate stability in even more detail when I look at Flomax cases in which any fluctuation in the chamber causes tremendous movement of the iris. With the Intrepid system, there is very little iris movement following an occlusion break. There are occasions of marked iris movement with the standard cassette cases.Micro-incisional surgery results in less irrigation flow; therefore, surge suppression is even more important in these cases. Raising the bottle does not solve the cause of postocclusion surge and can actually result in increased turbulence as well. The Intrepid FMS is designed to tackle the root cause of postocclusion surge by implementing stiffer aspiration tubing to suppress surge even better than the existing Infiniti cassette.
Dr. Lane: My parameters for phacoemulsification were
basically the same as yours, and I found I had to lower
them all when I started using micro-coaxial phacoemulsification.
I previously worked at 450 to 500 mm Hg of
vacuum, and with micro-coaxial, I was using 350 to
400 mm Hg. I lowered my aspiration flow rate from 35
or 40 mL/min to around 30 mL/min, and I had to raise
my bottle to 100 cm . With the Intrepid FMS, I have
brought all my parameters back to where I like them.
My bottle height now is approximately 90 cm , my flow
rate is back up to near 40 mL/min, and my vacuum
level is roughly 450 mm Hg, depending on the surgery I
am performing.
I also think the Intrepid system has improved my surgical
efficiency. When I was using torsional phacoemulsification
with my pre-Intrepid parameters, I was experiencing
occasional problems with clogging of the phaco tip.
As a consequence of the lower vacuum and depending
on the density of the lens, I was having to back off the
torsional and blend in more longitudinal ultrasound in
order to break up the lens without clogging. With the
Intrepid system, I see much less clogging, and I am able
to use 100% torsional ultrasound more often for the
same density of lens. This is an advantage to me because
I am thrilled with the cutting performance and lack of
repulsion of torsional ultrasound.
Where the Best Micro-Surgical ComponentsCome Together as One
From lens removal to lens implantation, the INTREPIDR Micro-c 除臭oaxial System delivers a complete micro-incisional solution, allowing you to perform surgery safely and efficiently through a single incision without altering your normal technique.
INFINITIR Vision System
Provides enhanced chamber stability and control
Utilizes the OZilR Torsional Handpiece for superior micro-incision procedures
The INTREPIDR Fluidic Management System (FMS)
Enhances fluidics during micro-coaxial phacoemulsification
Non-compliant tubing provides enhanced chamber stability
MicroSmoothR ULTRA Infusion Sleeves
Designed for micro-incision sizes 2.2mm - 2.4mm
Features a smooth external surface for reduced friction within the incision allowing for more freedom of movement and easier wound entry
Reduced stress on ocular tissue
AcrySofR Aspheric IOLs
Delivers advanced aspheric optics with thinner lens profile
Perfectly compliments modern micro-incision surgery
Provides ease of delivery in the bag through an un-enlarged micro-incision
ClearCut? Incisional Instruments
INTREPIDR knives are engineered to create precise, 2.4mm and smaller incisions
Improves blade tracking for superior entry and withdrawal
Designed to produce squared incisions and excellent wound architecture
Lower settings equals enhanced safety
Ozana Moraru MD said that the improved followability of
OZilR Torsional allows surgeons to reduce significantly their
aspiration and vacuum levels without any noticeable impact on
efficiency.
“This is particularly important when conducting
microincisional cataract surgery through 2.2 mm incisions. My
own personal settings are still pretty high, although they also
work very well with lower settings. I use an aspiration flow of
between 35 to 40 cc/min, usually fixed, and vacuum between
350 and 400 mmHg and 100 cm bottle height, with a dynamic
rise of 3 for very hard nuclei. For the final nuclear pieces, I
usually lower the dynamic rise to 1 or 0 and also the
aspiration rate because I want to be safer at this stage to
counter any post-occlusion surge,” she said.
All surgeons agreed that torsional ultrasound (for microcoaxial
incisions) has allowed them to lower the fluidics
parameters.Yuri Takhtaev MD said he now uses an aspiration
flow of 30 cc/min, vacuum of 350 mmHg and a bottle height
of 65 cms.
Ramon Lorente MD also uses similar settings: aspiration flow
of 30 or 35 cc/min, vacuum of 350 mmHg and a bottle height
of between 90 to 1 UNIQLO00 cm .
Marco Nardi MD said that he uses aspiration settings of 30
cc/min, 350 mmHg of vacuum and bottle height of 110 cm for
about 90% of patients.
“I lower these settings in certain cases, for example a high
myope with a deep anterior chamber where I have to be more
careful and chamber stability is critical,” he said.
For patients with weak zonules, subluxated lenses, traumatic
cataract, floppy iris syndrome, or those with an increased risk
of posterior capsule rupture, lowering the parameters should
help to offset any potential problems, advised Dr Moraru.
Master the handpiece
Marc Weiser MD said that while fluidics settings are
undoubtedly important, it is perhaps even more critical for
trainee surgeons to be able to use the handpiece in both
occlusion and non-occlusion mode.
“We have to appreciate the fundamentals as this is much
more important than fine-tuning the settings. If a surgeon
knows how to use the handpiece in these two modes, then
most settings will work okay,” he said.
Dr Weiser also warned surgeons to be on the lookout for
small pieces of nucleus that could become trapped in the angle
on both sides of the incision site and which might be missed
during phacoemulsification.
“I had to re-operate on a few patients because tiny pieces of
nucleus had become trapped in the angle and I could not see
them because they did not move during the surgery due to
the lack of repulsion with torsional ultrasound,” he said.
David Allen added that routinely performing stromal
hydration at the end of the surgery is a good means of flushing
out any fragments trapped in the angle.
Fixed versus linear for quadrant removal
Opinion among the surgeons was divided on the relative
benefits and drawbacks of using either fixed or linear settings
for quadrant removal.
Dr Takhtaev said that linear settings allow for greater
adaptability during surgery.
“With a linear setting the surgeon has more control over
leakage and anterior chamber stability from the foot pedal. I
never use fixed parameters and always use linear flow and
vacuum because of the extra control and responsiveness that it
gives me,” he said.
Dr Allen said that he uses fixed flow and vacuum for routine
cases, but occasionally switches to variable settings for removing
epinucleus.
Dr Nardi agreed that linear settings are useful for softer
cataracts.止汗方法 r>
Innovations in the Infiniti Vision System, the Intrepid FMS (Fluid Management System)
April 18, 2008 by Vantage Technology
The Infiniti Vision System (manufactured by Alcon Laboratories, Inc) has again excited the community of Cataract surgeons worldwide. The revolutionary Torsional technology has brought forth a rejuvenation of innovation in surgical techniques and superior patient outcomes. The latest addition to the Alcon product line is the Intrepid Micro-Coaxial System. One of its primary and most essential components is the Intrepid FMS (Fluid Management System). This system has been specifically designed to enhance fluidics in the surgical environment, especially for the surgeons who prefer the incision widths of 2.4mm or smaller. The rigid, low compliance tubing allows for a better and safer response even at higher flow rates and vacuum settings. It creates a greater level of chamber stability, provides better control, and allows for customization to individual patient needs. Overall, the Intrepid FMS (Fluid Management System) brings a new and exciting aspect to an already innovative approach to Phacoemulsification.
If you enjoyed this post, make sure you subscribe to my RSS feed!
Intrepid FMS allows me to use higher vacuum levels with lower bottle heights.Intrepid FMS limits iris movement following occlusion break in my Flomax patients.
Before any nuclear pieces enter the tip during phaco, a steady state of fluid movement exists, flowing out the infusion sleeve and going into the phaco aspiration port. As the tip begins to occlude with nuclear material, the pressure begins to rise in the anterior chamber and cassette tubing. When the tip becomes occluded, the vacuum level in the tubing will quickly rise until it reaches the maximum level. Once the occluding piece is emulsified, there will be a sudden drop in ocular pressure within the anterior chamber as fluid in the eye rushes into the aspiration port to satisfy the high vacuum that was created in the tubing. This is known as post-occlusion surge.Any significant post-occlusion surge is a dangerous situation. The anterior chamber shallows, and the iris moves toward the phaco tip. The suddenness of such an event may not allow the surgeon time to prevent posterior capsule rupture or significant iris trauma. Post-occlusion surge is less significant today with modern phaco technologies that incorporate newer fluidic management strategies, but it still occurs to varying degrees with all phaco platforms.Micro-Incisional Phaco Limits Irrigation With standard-size incisions ( 2.5 mm and above)—even with high-infusion sleeves— we still can see some small amounts of surge. But contro 戀鞋癖lling surge is more important with micro-incisional phaco because small incisions restrict the amount of irrigation that can enter into the eye even if the balanced salt solution (BSS) bottle is raised very high.Raising the BSS bottle higher is not innocuous. One downside of raising the BSS bottle is a concomitant increase of pressure in the eye. Another more potentially damaging side effect is an increase in anterior chamber turbulence from the high-pressure stream coming into eye. High turbulence can induce miosis during surgery and can adversely affect the corneal endothelium.Another strategy to combat post occlusion surge during microincisional phaco is lowering the fluidic settings by decreasing vacuum levels and aspiration flow rates to decrease the amount of post-occlusion surge.The problem with this strategy is that you end up decreasing your surgical efficiency as a consequence.Less Compliant Design The Intrepid Fluid Management System, or Intrepid FMS, (Alcon, Fort Worth , Texas ) is a less compliant (more rigid) tubing system than even the existing Infiniti FMS. The less compliance you have in a system, the less post-occlusion surge you’ll have. Lab tests demonstrate that the volume of fluid that rushes into the tip during occlusion breaks (surge) was markedly reduced with the Intrepid FMS. To determine if clinical experience would match the lab results, I compared, in masked fashion, chamber stability to the standard FMS to stability with the Intrepid FMS in approximately 100 patients. I used a rating scale from one to 10, on which a score of six or less represented some element of significant surge and a score of 10 was not possible to achieve with any fluidic system within a compliant chamber of the eye. A rating of 10 meant that nothing moved, that the surgeon would not be able to see any iris fluctuation or any shallowing of the chamber or posterior capsule movement. A rating of eight meant that I could barely see iris movement or posterior capsule movement and that the safety margins during phaco were excellent. With the Intrepid FMS, we had twice as many ratings of eight than with the existing system.The Importance of Confidence with Micro-Coaxial As I moved to torsional micro-coaxial phaco, surgery felt no different than with a 3.2-mm incision, so the transition was nearly seamless. Now, I no longer make an incision larger than 2.2 mm yet I still have great confidence in ocular stability using the Intrepid FMS. With the Intrepid FMS, I found that the posterior capsule routinely doesn’t normally budge, even when you’re working on the last quadrant. When aspirating that quadrant, even if I’ve reached vacuum levels at or near 400 mm Hg, the posterior facebook capsule is quite stable even without raising the BSS bottle. The Intrepid cassette has stiffer aspiration tubing, so some ergonomic compromise is noticeable, mostly during I%26A, when the handpiece typically is moved, twisted, and rotated more than during phaco.I can evaluate stability in even more detail when I look at Flomax cases in which any fluctuation in the chamber causes tremendous movement of the iris. With the Intrepid system, there is very little iris movement following an occlusion break. There are occasions of marked iris movement with the standard cassette cases.Micro-incisional surgery results in less irrigation flow; therefore, surge suppression is even more important in these cases. Raising the bottle does not solve the cause of postocclusion surge and can actually result in increased turbulence as well. The Intrepid FMS is designed to tackle the root cause of postocclusion surge by implementing stiffer aspiration tubing to suppress surge even better than the existing Infiniti cassette.
Dr. Lane: My parameters for phacoemulsification were
basically the same as yours, and I found I had to lower
them all when I started using micro-coaxial phacoemulsification.
I previously worked at 450 to 500 mm Hg of
vacuum, and with micro-coaxial, I was using 350 to
400 mm Hg. I lowered my aspiration flow rate from 35
or 40 mL/min to around 30 mL/min, and I had to raise
my bottle to 100 cm . With the Intrepid FMS, I have
brought all my parameters back to where I like them.
My bottle height now is approximately 90 cm , my flow
rate is back up to near 40 mL/min, and my vacuum
level is roughly 450 mm Hg, depending on the surgery I
am performing.
I also think the Intrepid system has improved my surgical
efficiency. When I was using torsional phacoemulsification
with my pre-Intrepid parameters, I was experiencing
occasional problems with clogging of the phaco tip.
As a consequence of the lower vacuum and depending
on the density of the lens, I was having to back off the
torsional and blend in more longitudinal ultrasound in
order to break up the lens without clogging. With the
Intrepid system, I see much less clogging, and I am able
to use 100% torsional ultrasound more often for the
same density of lens. This is an advantage to me because
I am thrilled with the cutting performance and lack of
repulsion of torsional ultrasound.
Where the Best Micro-Surgical ComponentsCome Together as One
From lens removal to lens implantation, the INTREPIDR Micro-c 除臭oaxial System delivers a complete micro-incisional solution, allowing you to perform surgery safely and efficiently through a single incision without altering your normal technique.
INFINITIR Vision System
Provides enhanced chamber stability and control
Utilizes the OZilR Torsional Handpiece for superior micro-incision procedures
The INTREPIDR Fluidic Management System (FMS)
Enhances fluidics during micro-coaxial phacoemulsification
Non-compliant tubing provides enhanced chamber stability
MicroSmoothR ULTRA Infusion Sleeves
Designed for micro-incision sizes 2.2mm - 2.4mm
Features a smooth external surface for reduced friction within the incision allowing for more freedom of movement and easier wound entry
Reduced stress on ocular tissue
AcrySofR Aspheric IOLs
Delivers advanced aspheric optics with thinner lens profile
Perfectly compliments modern micro-incision surgery
Provides ease of delivery in the bag through an un-enlarged micro-incision
ClearCut? Incisional Instruments
INTREPIDR knives are engineered to create precise, 2.4mm and smaller incisions
Improves blade tracking for superior entry and withdrawal
Designed to produce squared incisions and excellent wound architecture
Lower settings equals enhanced safety
Ozana Moraru MD said that the improved followability of
OZilR Torsional allows surgeons to reduce significantly their
aspiration and vacuum levels without any noticeable impact on
efficiency.
“This is particularly important when conducting
microincisional cataract surgery through 2.2 mm incisions. My
own personal settings are still pretty high, although they also
work very well with lower settings. I use an aspiration flow of
between 35 to 40 cc/min, usually fixed, and vacuum between
350 and 400 mmHg and 100 cm bottle height, with a dynamic
rise of 3 for very hard nuclei. For the final nuclear pieces, I
usually lower the dynamic rise to 1 or 0 and also the
aspiration rate because I want to be safer at this stage to
counter any post-occlusion surge,” she said.
All surgeons agreed that torsional ultrasound (for microcoaxial
incisions) has allowed them to lower the fluidics
parameters.Yuri Takhtaev MD said he now uses an aspiration
flow of 30 cc/min, vacuum of 350 mmHg and a bottle height
of 65 cms.
Ramon Lorente MD also uses similar settings: aspiration flow
of 30 or 35 cc/min, vacuum of 350 mmHg and a bottle height
of between 90 to 1 UNIQLO00 cm .
Marco Nardi MD said that he uses aspiration settings of 30
cc/min, 350 mmHg of vacuum and bottle height of 110 cm for
about 90% of patients.
“I lower these settings in certain cases, for example a high
myope with a deep anterior chamber where I have to be more
careful and chamber stability is critical,” he said.
For patients with weak zonules, subluxated lenses, traumatic
cataract, floppy iris syndrome, or those with an increased risk
of posterior capsule rupture, lowering the parameters should
help to offset any potential problems, advised Dr Moraru.
Master the handpiece
Marc Weiser MD said that while fluidics settings are
undoubtedly important, it is perhaps even more critical for
trainee surgeons to be able to use the handpiece in both
occlusion and non-occlusion mode.
“We have to appreciate the fundamentals as this is much
more important than fine-tuning the settings. If a surgeon
knows how to use the handpiece in these two modes, then
most settings will work okay,” he said.
Dr Weiser also warned surgeons to be on the lookout for
small pieces of nucleus that could become trapped in the angle
on both sides of the incision site and which might be missed
during phacoemulsification.
“I had to re-operate on a few patients because tiny pieces of
nucleus had become trapped in the angle and I could not see
them because they did not move during the surgery due to
the lack of repulsion with torsional ultrasound,” he said.
David Allen added that routinely performing stromal
hydration at the end of the surgery is a good means of flushing
out any fragments trapped in the angle.
Fixed versus linear for quadrant removal
Opinion among the surgeons was divided on the relative
benefits and drawbacks of using either fixed or linear settings
for quadrant removal.
Dr Takhtaev said that linear settings allow for greater
adaptability during surgery.
“With a linear setting the surgeon has more control over
leakage and anterior chamber stability from the foot pedal. I
never use fixed parameters and always use linear flow and
vacuum because of the extra control and responsiveness that it
gives me,” he said.
Dr Allen said that he uses fixed flow and vacuum for routine
cases, but occasionally switches to variable settings for removing
epinucleus.
Dr Nardi agreed that linear settings are useful for softer
cataracts.止汗方法 r>
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