Cataract surgery has evolved from simple procedures such as couching and extracapsular and intracapsular cataract extraction to phacoemulsification. These early techniques had increased complications including infections, posterior capsular opacification, retinal detachment, and retained cataracts that could lead to vision loss.1,2,3
- Couching (~600 BC): A sharp need is used to pierce near the corneal limbus until the surgeon can extract the lens and dislodge the cataract into the vitreous chamber and out of the visual axis.1,3
- Extracapsular cataract extraction (1747): Credited to the French surgeon Jacques Daviel, a corneal incision > 10mm is created and a blunted needle punctures the lens capsule. The lens is extracted using a spatula and curette.2,3
- Intracapsular cataract extraction (1753): English surgeon Samuel Sharp removed the opacified lens and surrounding capsule in one piece by lysing the zonular fibers. This lens-bag complex was removed via a large limbal incision.1,3
- Phacoemulsification (1967): American ophthalmologist, Charles Kelman used ultrasound to break up the cataract and aspirate the lens particles. Using topical anesthetics and foldable intraocular lens implants, phaco has rapidly become the standard for cataract surgery. As phaco has improved, incision sizes have decreased from 10mm to 3mm, resulting in faster recovery times, greater surgical stability, and lower complication rates.3 In 2010, Femtosecond Laser-Assisted Cataract Surgery (FLACS) was approved by the FDA and it provides a less invasive technique and greater surgical predictability.4,5 FLACS is typically performed with phaco.5
Limitations and Challenges of Traditional Phaco
While these technological advancements have benefited patients, they have also increased the complexity of cataract surgery. Phaco involves several moving parts using the handpiece, console, and foot pedal. The bulkiness of phaco machines and increased maintenance and monitoring demands limit portability and patient access.
Phaco also increases capital expenditure costs related to service contracts, financing, and the appropriate floor space required to support the machinery. This limits the availability of phaco as a surgical option in office-based surgery spaces and underdeveloped countries.6
Phaco also increases capital expenditure costs related to service contracts, financing, and the appropriate floor space required to support the machinery. This limits the availability of phaco as a surgical option in office-based surgery spaces and underdeveloped countries.6
Since phaco handpieces contain bacteria, rigorous sterilization protocols are important due to the higher risk of cross-contamination and toxic anterior segment syndrome (TASS).6,7
Additional challenges encountered during phacoemulsification include patient cooperation, particularly maintaining stillness during surgery. This is challenging for patients with anxiety or cognitive issues, such as those with dementia.8,9
During phacoemulsification, the duration of the procedure and ultrasound energy can cause corneal endothelium damage. The higher ultrasound energy causes damage to adjacent ocular tissue which can lead to corneal endothelial dysfunction and significant endothelial cell loss. This can be an issue with patients with endothelial issues such as Fuchs’ dystrophy.10
Changing the Paradigm with MICOR
MICOR presents an alternative to phaco. Its design delivers 1,000x less energy at 40Hz than phaco using a blunt tip to reduce the risk of incidental damage to collateral tissue like the iris and capsular bag.6,7 MICOR tips generate less heat compared to phaco tips. Fragmentation efficiency is improved by a positive displacement pump in the handpiece that creates an asynchronous peristaltic vacuum at the tip.6
MICOR also has a smaller footprint because there is no need for a console and foot pedal.6 This diminished footprint reduces turnover time because its disposable tips can be quickly replaced ensuring maximum efficiency in the operating room.7 This reduced footprint also translates to reduced costs because there is no need for service agreements or capital equipment expenditure.6
Because MICOR is a single-use system using disposables, there is a reduced need for sterilization as only the miCOR drive needs to be sterilized.6
As with any kind of refractive surgery, patient selection is important. Phacoemulsification can lead to endothelial cell loss due to fluid turbulence and ultrasound energy. This results in increased post-operative corneal edema risk. Patients with corneal conditions such as Fuchs’ dystrophy have an even higher risk of corneal decompensation after cataract surgery.11
These patients are great candidates for MICOR due to lower energy and reduced fluid consumption.6 It is also important to understand that cataract grading severity can affect extraction time and outcomes since every surgeon grades differently and cataract density can impact patient candidacy. Therefore complex cases should be avoided, especially while learning to use the device.7
Integrating MICOR Into Your Practice
MICOR is a great addition to surgical practice but there are a few things to consider. There is a bit of a learning curve particularly because the entire procedure is controlled by the surgeon’s dominant hand. There is no foot pedal or console and the user will need to adapt to the absence of ultrasound, refine surgical technique, and rely on a second instrument. It takes time to adapt to using MICOR and workflow may need to be adjusted pre-, intra-, and postoperatively.7
There are a few things to consider before adopting MICOR into practice:
- Assess the physical space requirements and determine if any modifications are required to accommodate MICOR technology in the surgical suite.
- Staff must be properly trained regarding patient education and workflow.
- Assess the costs and maintenance for implementing MICOR in your practice.
- Identify patients that would benefit from MICOR the most such as patients with certain corneal conditions. When offering patients a premium experience, explain to the patient that MICOR is the least invasive approach to provide the best possible outcomes for their specific case.
Conclusion
Technological advancements in cataract extraction have led to the creation of MICOR changing how cataract surgery is performed. It has a smaller footprint than phaco, reducing demand for rigorous sterilization and increasing efficiency, making it a great fit for office-based surgery. This small footprint also translates to cost savings and profitability. It allows for better control suitable for delicate cases leading to lower potential for complication, potentially faster recovery time, and reduced incidence of post-operative inflammation.
