Keys to optimising phaco efficiency

I have always been driven to find the sweet spot where surgical precision, patient comfort and workflow efficiency intersect. For a high-volume cataract surgeon, variability can be a barrier to achieving efficiency. Integrating technologies that help optimise surgical workflow and streamline our process has become the cornerstone to achieving surgical efficiency and reducing variability in my clinic.

Surgical efficiency is often discussed in terms of increasing surgical volume, reducing procedure times and complications and maximising throughput. Another frequently overlooked advantage is predictability. When my workflow and outcomes are consistent and reliable, I am more productive, confident and focused, and less fatigued. The result is a calmer, more reassuring experience for patients.

A balancing act

The balancing act between efficiency and patient comfort is growing. Despite an increased demand for cataract surgery due to the aging population, the ophthalmology workforce is shrinking. Studies show that by 2035, there will be 12% fewer individuals working in ophthalmology.¹^,² For me, staying ahead of the patient curve requires making thoughtful choices about which technologies I adopt to support efficiency and how I implement them to streamline my workflow without sacrificing surgical safety and efficacy.

Technologies such as digital intake systems, cloud-based data sharing, and surgical planning platforms like Eyetelligence (Bausch + Lomb) and Zeiss Veracity (Carl Zeiss Meditec) help support preoperative workflow by eliminating bottlenecks and improving communication across diagnostic devices and care teams. Some of the most transformative changes in my practice, however, have come from intraoperative technologies such as femtosecond laser-assisted cataract surgery (FLACS), real-time guidance systems like Cassini Connect O.R. (Cassini Technologies), and the R-Evo Smart phacoemulsification (phaco) platform (BVI Medical). These tools work together to reduce surgical time and give me greater control and more consistent results.

Energy efficiency

Phaco energy efficiency is influenced as much by surgeon experience and preferred nuclear disassembly techniques³ as by the technologies we use. For me, the combination of FLACS with an energy-efficient phaco platform such as R-Evo Smart is especially helpful in streamlining cataract surgery. It decreases the time spent on various manoeuvres, including capsulotomy, lens softening and removal and even astigmatism correction, and has led to more precise case management and reduced tissue damage.

The surge control, total ultrasound time and fluid consumption of a phaco platform directly influence procedural stability, surgeon control and patient comfort. Established strategies to reduce ultrasound time include using torsional and burst phacoemulsification,⁴ modifying ultrasound power time and duration, altering duty cycle on and off times, selecting a pulse rate and duty cycle based on the surgical situation⁵ and performing cataract surgery at a more physiologic IOP.^6-8 The R-Evo Smart Agile Fluidics system adjusts IOP in real-time based on aspiration demand, offering a more physiologic environment. Additionally, the platform incorporates Minimal Stress technology to ensure the phaco tip maintains consistent movement regardless of cataract density, which also helps reduce total ultrasound time.

In a prospective study conducted in 301 eyes undergoing routine phacoemulsification or FLACS, the R-Evo Smart (n = 155) provided significantly better surgical efficiency as measured by total ultrasound time during lens removal and fluid consumption during lens removal, irrigation and aspiration than the Centurion Vision System (Alcon; n = 146).⁹

The mean ultrasound time in the routine phaco and FLACS groups was more than 50% faster in the R-Evo group (18.99 ± 12.85 sec vs 40.24 ± 21.91 sec; P < .01). Similar results were seen in a subset of the routine phaco eyes (R-Evo group, 98 eyes; Centurion group, 63 eyes), where the mean total ultrasound time was 19.96 ± 11.20 sec and 42.84 ± 28.35 sec (P < .01), respectively (Table).

Across all eyes and in the phaco subgroup eyes, the mean total estimated fluid aspirated/drainage bag weighting in the R-Evo Smart and Centurion groups was 53.00 ± 14.56 g and 54.33 ± 14.88 cc (P < .21), respectively, and 55.95 ± 14.76 g and 55.97 ± 13.62 cc, respectively (P = .49).

There was no significant difference in cataract grade between the R-Evo and Centurion groups (3.07 ± 0.78 vs 2.96 ± 0.85; P = .12) or fluid consumption. However, a correlation was noted between cataract grade and ultrasound time in both groups.

Enhancing patient care

It is worth emphasising that streamlining surgery does not mean cutting corners. The more consistent and efficient our cataract surgery procedures are, the better the care we can provide for our patients. Incorporating precision procedures such as FLACS reduces surgical time and supports highly repeatable manoeuvres that improve outcomes. When FLACS is paired with the R-Evo Smart system, the synergy further enhances control and predictability.

This dual approach has enabled me to increase surgical throughput without sacrificing quality. And because each procedure is smoother and more controlled, the transition between cases is faster, helping me treat more patients while preserving energy and focus throughout the day.

Conclusion

Having control of the surgical environment and my tools helps me deliver the best possible outcomes. It equips me to manage a growing demand for cataract surgery without burning out or letting the patient experience discomfort. Incorporating state-of-the-art technologies helps me reduce surgical variability, improve efficiency, build confidence and deliver high-quality and consistent care.

Marta Ibarz, MD, PhD | E: mibarz@oftalvist.es

Ibarz is a cataract and refractive surgeon at Grupo Oftalvist, Oftalvist Juan Bravo, Madrid, Spain. Financial disclosure: Consultant, BVI Medical.

References

1. World Health Organization. Blindness and vision impairment. August 10, 2023. Accessed October 8, 2024. https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment

2. Berkowitz ST, Finn AP, Parikh R, Kuriyan AE, Patel S. Ophthalmology workforce projections in the United States, 2020 to 2035. Ophthalmology. 2024;131(2):133-139. doi:10.1016/j.ophtha.2023.09.018

3. Bui AD, Sun Z, Wang Y, et al. Factors impacting cumulative dissipated energy levels and postoperative visual acuity outcome in cataract surgery. BMC Ophthalmol. 2021;21(1):439. doi:10.1186/s12886-021-02205-w

4. Yang WJ, Want XH, Zhao F, Mei ZM, Li S, Xiang Y. Torsional and burst mode phacoemulsification for patients with hard nuclear cataract: a randomized control study. Medicine (Baltimore). 2019;98(22):e15870. doi:10.1097/MD.0000000000015870

5. McKinney S. Phaco update: getting the right setting. Review of Ophthalmology. April 15, 2021. Accessed October 8, 2024. https://www.reviewofophthalmology.com/article/phaco-update-getting-the-right-setting

6. Rauen MP. Phacoemulsification at high IOP and physiologic IOP: impact on anterior segment physiology. Paper presented at: American Society of Cataract and Refractive Surgery Annual Meeting; May 5-8, 2023; San Diego, CA.

7. Rauen MP. Phacoemulsification at high IOP and physiologic IOP: impact on posterior segment physiology. Paper presented at: ASCRS Annual Meeting; May 5-8, 2023; San Diego, CA.

8. Beres H, de Ortueta D, Buehner B, Bernd Scharioth G. Does low infusion pressure microincision cataract surgery (LIPMICS) reduce frequency of post-occlusion breaks? Rom J Ophthalmol. 2022;66(2):135-139. doi:10.22336/rjo.2022.27

9. Ibarz-Barberá M, Orts-Vila P, Martínez-Galdón F, Martín-García N, Tañá-Rivero P. Surgical efficiency comparison between two phacoemulsification systems. Clin Ophthalmol. 2024;18:1095-1102. doi:10.2147/OPTH.S453899