DEDICATED TO EXCELLENCE IN OPHTHALMOLOGY

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1 26 Plaza Drive Westmont, IL USA Phone: Fax: Customer Service: Edward J. Holland, MD Cincinnati, OH Vision Fall NEWS 2006 DEDICATED TO EXCELLENCE IN OPHTHALMOLOGY NEW DIMENSION TO CATARACT SURGERY As there are very few modifications necessary to implant the Toric IOL during routine cataract surgery, such as the IOL calculation for cylindrical power and axis of placement, the marking of the eye, and the on-axis placement of the IOL, cataract surgeons will soon become successful at regularly implanting the Toric IOL. The marking procedure is done in two steps. First, the surgeon uses the AE-2791 Pre-Op Toric Reference Marker to place reference marks on the 3 and 9 o clock meridians at the limbus, either in the preinduction room or in the OR. This step should be done with the patient sitting upright to avoid the effect of cyclorotation when the patient moves to a supine position for the cataract procedure. The surgeon then performs a standard capsulorrhexis, hydrodissection, and phacoemulsification. After cataract removal, using the reference marks of the AE-2791, the PRE-OP TORIC REFERENCE MARKER AE-2791 The reference marker features a radial pattern at the 3, 6 and 9 o clock positions. Inking can be accomplished with either a pen or pad The marker is used from the temporal position with the patient sitting Patents Pending The marking patterns are on both the anterior and posterior surface of the instrument, so it can be utilized for both the left and right eyes surgeon places axis marks using the AE-2792, Intra-Op Toric Axis Marker, to delineate the steep axis of astigmatism upon which the IOL should be aligned. Precisely aligning the IOL with the predetermined axis of placement involves gross alignment, viscoelastic removal, and final alignment. The first occurs after the IOL s rotated to a point that is 15 to 20 degrees counterclockwise of the final axis location. The surgeon must ensure that the IOL does not rotate beyond the final axis during the viscoelastic s removal. It is important to remove all of the viscoelastic, including on the posterior side of the lens, because remnants could cause rotation of the IOL postoperatively. In summary, I believe that excellent results can be achieved with the Toric IOL and ASICO s Toric Markers, with minimal modification to ophthalmologists surgical technique. Because of its rotational stability and advanced IOL calculator, this new lens enables surgeons to correct astigmatism precisely and achieve distance-vision spectacle freedom for more patients. INTRA-OP TORIC AXIS MARKER AE-2792 The fixed axis marks are easily aligned with the pre-op reference markers The rotatable marker barrel allows precise location for the steep meridian Built-in keratometer used as a quick reference to confirm the steepest meridian TRANSITIONING TO MICRO COAXIAL Patents Pending Takayuki Akahoshi, MD Tokyo, Japan I have successfully operated on 5,000+ cases using Alcon s Ultra Sleeve, ASICO instruments and my Counter Traction Implant Technique in order to complete Micro Coaxial Phaco and IOL implantation in a 2.2mm incision. One of the most critical instruments to successfully implant the Acrysof IOL in a 2.2mm incision or smaller is the ROYALE SPRING INJECTOR AE-9045SP AE-9045SP, ASICO Royal Spring Injector along with Alcon s Monarch C cartridge. This injector, which features an all titanium body and gold colored tip, enables single handed implantation allowing the surgeon s other hand to support the eye through the side port with the AE-2530 Nucleus Sustainer. To see more about my technique please see the table labeled Pearls for Micro Coaxial on page 4.

2 Thomas John, MD Chicago, IL Identification of Step STEP BY STEP FOR DXEK/DSAEK One of the main reasons the initial transition to PLK and DXEK/DSAEK was difficult was due to the fact that surgeons did not have adequate instrumentation for the procedure. As all instrumentation at the time was designed to work on the floor of the eye as opposed to the ceiling, it made it difficult to manipulate the Difficulty Encountered instruments within the 360 degrees of the anterior chamber without having to exit the incision multiple times. With this in mind I designed the following set of instruments in coordination with ASICO to have a unique curvature in order to easily and efficiently work on the ceiling and simplify the transition into DXEK/DSAEK. New Instrument Designed Removal of Descemet s membrane (DM) and endothelium Reverse Sinskey Hook is difficult to use, as it was not designed to work on the ceiling of the cornea. John Dexatome DXEK/DSAEK Spatula AE-2872 Complications with endothelium removal Dealing with the fragments of endothelium Complications include; irregular tears in DM, creation of unwanted stromal strands, inability to consistently remove DM as a single disk, and having to enter AC more than once to complete the 360 degree DM tear. Need three instruments to remove DM, namely, the reverse Sinskey hook and Dexatome and Stripper. Very difficult to remove fragments without damaging the stroma John DXEK/DSAEK Descemet's Stripper AE-2874 John Retrocorneal Super Micro Forceps AE-4962, Scissors AE-5762 Preparation for insertion of tacofolded donor disk Reverse Sinskey Hook was used to roughen the peripheral exposed stroma within the area of Descemetorhexis. However, it was difficult to use as it was not designed to work on ceiling of the cornea. John DXEK/DSAEK Stromal Scrubber AE-2878 Insertion of taco-folded donor corneal disk Fixation of donor cornea Kellman Forceps holds the folded disk in the horizontal plane and the hand must rotate out or in. Other forceps with tissue clearance are also oriented to hold the disk in the horizontal plane. Also, the blades of these forceps release the disk less easily, especially when the AC is not deep enough for this maneuver. Reverse Sinskey Hook is difficult to use, as it was not designed to work on the ceiling of the cornea. John DXEK/DSAEK Inserting Forceps AE-4227 John DXEK/DSEK Fixation Hook AE-2182 Wrinkle removal Lindstrom Roller is designed for use with LASIK. It has been used for DXEK/DSAEK, however, it lacked curvature along the horizontal axis which created the need for multiple rolls. John DXEK/DSAEK Glider AE-2879

3 EASY ADAPTATION TO ICL Roberto Zaldivar, MD Mendoza, Argentina I have been involved with ICL since the evolution stage in 1993 and have implanted 4,400 ICL to date, including 2,200 of the VA model since Since its introduction, the ICL has undergone many design and technique changes; based on my experience with these implantations I have designed the following instruments for surgeons to be able to easily implant an ICL with a minimum learning curve. The instruments that I have designed include: AE ZALDIVAR (ZAP II) DIAMOND KNIFE The ZAP II Diamond Knife is designed for anterior segment procedures including Micro Phaco, cataract-scleral and clear corneal incision, trabeculotomy, implantation of ICL and others 10 facet blade has side cutting edges for extension of the wound 1.0mm blade width Design of the blade eliminates the need for viscoelastic to create high ocular pressure for clear corneal procedure as with other diamond knives Flattened tip gives surgeons controlled entry Complimentary sterilization tray AE-4965 ZALDIVAR IRRIDECTOMY FORCEPS Angled 90 tip is perpendicular to the iris plane for easy pickup of the iris Tips have serrated jaws to effectively grasp the iris 23 gauge straight instrument with round handle for easy maneuverability Forceps can be used through the side-port incision Advanced Cutting Technology Reproducible Incisions Hydration Minimized Ideal for Wound Extension for IOL implantation Cost Effective TM AE ZALDIVAR/KRAFF ICL PACman FORCEPS Features specially designed jaws with atraumatic ridges to grasp the ICL without damage to the IOL, rounded edges and a hole on the upper jaw for the easy identification of the IOL allowing improved visualization The gentle curve at the tip of the jaws contours to the curvature of the optic so that it is not touched by the forceps The length of the jaws aligns with the length of the haptics Jaws open wider for an easier grasp AE ZALDIVAR ICL MANIPULATOR Manipulates the inferior and superior haptic of the lens to place under the iris Designed to be used with myopic and hyperopic lenses Manipulator features a shorter side to introduce the proximal part of the lens and a longer side for the distal Posterior side of manipulator features a fine sandblasting for ease of manipulation of the ICL Designed to be used through side-port incision NEW PRODUCT RELEASE Introducing the sharpest blade for Micro Coaxial Angled Clear Corneal Blade AS mm AS mm Call for complimentary sample ICL is a registered trademark of Staar Surgical. AS mm Micro Coaxial is a registered trademark of Alcon Labs.

4 PEARLS FOR MICRO COAXIAL DIFFICULTY ENCOUNTERED SOLUTION INSTRUMENTS Takayuki Akahoshi, MD Tokyo, Japan INCISION Difficulty making an ideal incision Use a sharp diamond keratome of appropriate size. Choose the appropriate diamond keratome according to the sleeve. Based on the IOL power, we can adjust the incision size by controlling the insertion depth of the keratome. I do not make a long corneal tunnel. It will constrict the sleeve and reduce the irrigation. If the nucleus is prechopped and phacoemulsified by the Burst mode, there will be no thermal or mechanical damage of the incision and it will be easily sealed without hydrating the stroma. My tunnel length is usually less than 1.0mm. AE Akahoshi Ultra Diamond Keratome AE Akahoshi Nano Diamond Keratome AE-8190 Difficult to control the insertion depth of the blade Fix the eye ball by grasping the bulbar conjunctiva. AE Akahoshi Universal Forceps Difficulty implanting AcrySof due to the leakage of OVD Use a small side port knife. If the side port is too large, there will be a leakage of OVD when the IOL is injected by the Counter Traction technique. AE Akahoshi Sub II Sideport Diamond Keratome AE-4345 CAPSULORRHEXIS Difficulty making a capsulorrhexis through a small incision Fill up the anterior chamber with Viscoat, which can protect the corneal endothelium during phaco. As it has dispersive property, it does not easily leak from the incision and maintains a deep anterior chamber. Any conventional capsulorrhexis forceps can be used, however cross action forceps causes less leakage of Viscoat. AE Akahoshi Capsulorrhexis Cross Action Forceps AE-7636 HYDRODISSECTION It is not possible to rotate the nucleus after bisecting the nucleus by prechop. Generally much of the cortex remains after phaco. Cortical aspiration damages the incision by the mechanical manipulation at the incision Adequate hydrodissection of the nucleus. Put a 2.5ml small syringe filled with BSS to the cannula and perform cortical cleaving hydrodissection. AE Akahoshi Hydrodissection Cannula AE-4190 AE-4253 SEALING IOL IMPLANT PHACO Thermal burn and mechanical damage of the incision Cannot set the AcrySof properly in the cartridge IOL getting stuck in the cartridge Cannot insert the IOL through the incision Difficulty to seal the incision Prechop the nucleus to reduce the U/S time. ASICO's Type II prechoppers open wider in the anterior chamber through a small incision. Use the Nucleus Sustainer, AE-2530, to perform the Counter Prechop technique for a dense nucleus. Use the special loading forceps. Any single piece AcrySof can be implanted using a C cartridge. Use Provisc which is easier to remove after implanting the lens. If the IOL setting in the cartridge was not appropriate, the lens will not be delivered by pushing the plunger. Provide a counter force to the cartridge and inject the lens quickly. Don't damage the incision during the phaco and I/A. Change the incision size according to the IOL power. AcrySof IQ SN60WF is an ideal IOL to implant through a micro coaxial incision as its optic is about 9% thinner than the conventional AcrySof Natural SN60AT. Inject BSS with AE-7636 without pressing the incision. AE Akahoshi Sub II Combo Prechopper AE Akahoshi Universal II Prechopper AE Akahoshi Acrylic IOL Loading Forceps AE Akahoshi Combo Inserter AE Akahoshi Forceptor AE-9045SP - ASICO Royal Spring Injector AE Akahoshi Sustainer AE Akahoshi Hydrodissection Cannula AE-7636 AcrySof is a registered trademark of Alcon Labs.

5 Warren E. Hill, MD Mesa, AZ PRECHOPPING JUST GOT EASIER For the surgeon getting started with prechopping, the first few cases are sometimes difficult. This is often because the beginning surgeon does not bury the instrument deep enough into the nucleus, resulting in an incomplete crack. A concern by many who are new to prechopping is that the instrument may be going too deep, or that an undue amount of stress is being placed on the zonules. In reality, the vertical dimension of the instrument is typically less than the thickness of the lens and I have never experienced a zonular dialysis as a result of prechopping. When an incomplete crack occurs, all too often surgeons simply go back to what it was they were doing before, never to try this again. This new design incorporates several features that should make it easier for both the novice and experienced surgeon to incorporate Dr. Akahoshi s marvelous technique into their surgical routine. For the 2+ nucleus, this design will allow for easier AKAHOSHI SUB II COMBO PRECHOPPER AE-4190 Suitable for Karate prechop (vertical prechop) Safely prechop nuclei of grades 1 to 2 Sharp edge used to insert into the nucleus Blunt edge used to ascertain complete division Designed to be used in incisions of 2.0 to 2.2mm AKAHOSHI UNIVERSAL II PRECHOPPER AE-4192 Safely and effectively prechop nuclei of grades 2 to 4 For prechopping hard nuclei, the Akahoshi Nucleus Sustainer AE-2530/AE-2536 is used with the counter-prechop technique Designed to be used in incisions of 2.0 to 2.2mm AKAHOSHI NUCLEUS SUSTAINER AE mm tip effortlessly supports even the deepest part of the nucleus 0.4mm microball protects the posterior capsule Angle to tip: 1.9mm Can be used through the side-port incision Also ideal to use with the Akahoshi Prechopper series for the counter prechop technique Can also be used for manipulating the iris, nucleus, IOL, etc. HILL PRECHOPPER AE-4193 penetration, with initiation and propagation of the first crack using Dr. Akahoshi s standard karate pre-chop technique. The sharp tip, and thin edges, allow the instrument to move more easily through nuclear material. For the 3+ nucleus, or harder, the sharp tip and razor sharp internal cutting edge allows the surgeon to both penetrate and slice through the nucleus using a downward movement of the tip while simultaneously elevating the handle. This allows the curved, sharp inside edge of the instrument to cut through the nucleus using both vertical and horizontal forces, much like the cutting action of a saber blade. After each pre-chop has been initiated, the instrument is then turned over and its smooth edge is used to complete the crack all the way down to include the posterior plate of the lens. Since its introduction by Dr. Takayuki Akahoshi, prechopping the nucleus has evolved into a highly sophisticated surgical maneuver that both reduces phaco time and fluid flow into the eye. The goal of this instrument is to allow a greater number of surgeons to embrace pre-chopping for normal and harder nuclei without the need for a second instrument. PREMIUM CHOICES IN PRECHOPPING INAMURA EAGLE PRECHOPPER AE-4293 Recommended to make an incision in the center of the nucleus as it helps split it without applying any pressure on the zonules Narrow tip is easy to insert into the denser nucleus Enables the division of dense nucleus without counter force Tip shape makes nucleus rotation easier in the capsular bag AKAHOSHI HYBRID COMBO PRECHOPPER AE-4286 Can be used for prechopping grade 1 to 4 nuclei For grade 1 and 2 nuclei, karate prechop can be performed more easily Can be used by the counter prechop technique with a nucleus sustainer for grades 3-4 nuclei Sharpened angular edge improves insertion into the nucleus and makes nuclear rotation easier Rounded side of the blade can be used safely to attain complete division AKAHOSHI NUCLEUS RING SUSTAINER AE-2536 Used to hold the hard nucleus firmly during the prechopping technique Features a ring to fit under the posterior plate of the nucleus and secure the lens for vertical prechop Instrument is designed for maximum protection of the posterior capsule Ring diameter is 1.0mm

6 26 Plaza Drive Westmont, Illinois U.S.A. First Class US Postage Paid Downers Grove IL Permit #163 AAO LAS VEGAS Visit us at BOOTH 2625 NEW DEVELOPMENTS IN LRI Many patients now expect not only a successful cataract extraction but also an improvement of uncorrected visual acuity. The surgeon must beware that the spherical equivalent has to approximate to zero with the accurate lens power calculations and both pre-existing and surgically induced astigmatism to have been reduced. Limbal relaxing incision (LRI) is a very useful and safe Eriko Fukuyama, MD Fukuoka-shi, Japan technique for reducing corneal astigmatism and can be performed at the time of cataract surgery; especially when implanting the new multifocal and aspheric IOLs. However, the surgeon needs to increase the IOL power by D if LRI is performed at the time of cataract surgery, because LRI with long incisions has a radial keratotomy effect. As compared with Astigmatic Ketatotomy at the clear cornea the complications in LRI are reduced. However, LRI of narrow and deep incisions occasionally causes the cornea to become a pyramid shape, which is an over correction and causes an axis displacement. We can avoid these complications by making the LRI incision shallower and longer. I have proposed this new procedure named Long and Shallow Limbal Relaxing Incision (LSLRI) for the past four years. Initially, I completed about three hundred Astigmatic Ketatotomies at the clear cornea, then about six hundred LRIs and most recently about four hundred LSLRIs done at the time of cataract surgery. In order to receive the nomogram, please contact ASICO. Using the AE-2812 Fukuyama LRI Marker make two reference marks at the limbus on the 3:00 and 9:00 positions using the slit lamp with the patient in the sitting position, in order to avoid any error due to the torsion of the eye as the patient lays down. Both of the LRI markers I designed combine axis and degree marks. They are positioned so that the 90 axis mark lines up with the 6:00 mark at the inferior limbus and the center of the marker lines up with the 9:00 mark in against-the-rule astigmatism cases. Coating the bottom of these markers with gentian violet is helpful in order see the degree marks easily. The AE-2812 Fukuyama LRI Marker can mark up to 60. The AE-2829 Fukuyama LRI Marker can mark up to 120 and each tick mark is 10. I commonly use the AE-2812 Fukuyama LRI Marker to perform LRI up to 60 and the AE-2829 Fukuyama LRI Marker to perform LRI of more than 60 or to perform LRI for oblique astigmatism. The AE-2762 Fukuyama Fixation Ring with Degree Markings was designed for LRI with long incisions because it is easier to maneuver a diamond knife within the open space of the ring. The narrow width of the footplate on the AE-8194 Fukuyama LRI Diamond Knife helps to prevent corneal epithelial detachments, permits arcuate incisions and enables viewing of the operating field easily. The micrometer also allows precise settings in increments of 10 microns and the retracting mechanism is useful for blade protection and depth setting memory. AE-2762 Fukuyama Fixation Ring AE-2812 Fukuyama LRI Marker AE-2829 Fukuyama LRI Marker AE-8194 Fukuyama LRI Diamond Knife Phone: Fax: Customer Service: Website: info@asico.com BR132-06