Reprints:Richard J. Fugo, MD, PhD, P.O. Box 1700, Norristown, PA 19404.

Dr. Fugo has a financial interest in the Fugo Blade™, which is produced by MedisurgResearch and Management Corporation, Norristown, Pa. More information can beobtained by calling (610) 277-3937 or at www.fugoblade.com.

O R I G I N A L A R T I C L E

ANN OPHTHALMOL. 2002;34(1):12–1412

The Fugo Blade™ was recently approved for anteri-or capsulotomy by the US Food and Drug Admin-

istration (FDA; Fig 1).1 This device was the topic ofthe John H. Sheets Memorial Lecture at the 2001American College of Eye Surgeons meeting in BalHarbour, Fla.2 The device operates on flashlight-sizedrechargeable batteries, yet it cuts sharper than a dia-mond blade. It creates an incision by focusing a low-power electromagnetic field into a 50-µm columnaround a hair-thin blunt cutting filament.3 Thisfocused energy causes the molecules in the 50-µmcolumn around the incising filament to emit a visiblelight (Fig 2).4 The Fugo Blade is the only electrosurgi-cal unit approved for intraocular cataract surgery inthe United States and thus has been awarded aunique FDA product code.

No red reflex is needed; moreover, the surgeonmerely traces or draws the capsulotomy on the anteri-or capsule. Unexpected tears in capsule can be easilyand quickly controlled by the Fugo Blade in seconds.5

The elasticity of a capsulorhexis is unparalleled;nonetheless, a Fugo Blade capsulotomy offers power-ful advantages to the cataract surgeon.

New technology is usually accepted as the benefitsare realized by the ophthalmic community.6 Each newtechnology is most effective when surgical techniquesare employed that favor the new technology.7 A noveltechnique is herein presented, which is highly effec-tive when used in conjunction with the Fugo Blade.The technique is called PhacoXcap™.

Richard J. Fugo, MD, PhD

PhacoXcap™Cataract Surgery

Modern cataract surgery involves removing cloudy lens cortex and

nucleus through 2 openings in the eye: the capsulotomy and an inci-

sion in cornea or sclera. A new approach, PhacoXcap™, provides

the ease of planned extracapsular surgery with the closed-system

safety of phacoemulsification. PhacoXcap allows quick removal of

the intact cortex and nucleus out of the lens bag and into the ante-

rior chamber for iris plane phacoemulsification.

A B S T R A C T

Surgical MethodThe new technique, PhacoXcap, combines the ease ofextracapsular cataract surgery with the closed-systemsafety of phacoemulsification. Cataract surgery iseffectively removing the cortex and nucleus through 2ostomies, or openings, namely, the capsulotomy andthe corneal incision. PhacoXcap allows the nuclear-cortical bulk as a single mass to be passed quicklythrough the Fugo Blade capsulotomy, then easily andquickly phacoemulsified in the iris plane.

Once the nucleus and cortex are evacuated fromthe lens bag and then lodged in the iris plane, many ofthe perils of cataract surgery are eliminated. The FugoBlade requires no red reflex, so the most maturecataracts are easily dealt with using the PhacoXcaptechnique.

Following creation of a 2.8- to 3.0-mm scleral-corneal incision, the viscoelastic cannula is placedunder the iris. A small amount of viscoelastic pushes

the iris upward and away from the lens. This preventsincision of the iris with the Fugo Blade and allows cre-ation of the Fugo Blade capsulotomy under the iris.

A 7- to 8-mm Fugo Blade capsulotomy is then per-formed (Fig 3). The goal is to leave a 2-mm rim of ante-rior capsule in order to stabilize lens zonules andstabilize the intraocular lens (IOL) haptic. An olive-tipped cannula is then placed against the interior sur-face of the capsule. A wave of balanced salt solution isthen gently injected in order to hydrodissect a cleav-age plane between the capsule and the cortex.

The phacoemulsification tip is then used to impalethe center of the nucleus. Then, the entire cortex andnucleus are gently rocked back and forth severaltimes with the phacoemulsification handpiece. I thengently dial and lift the nucleus and cortex in one pieceout of the lens bag and through the pupil. In Fig 4, thecataractous material has been removed from the firstostomy opening in the eye, and the cataractous bulknow sits near the iris plane.

This seemingly simple maneuver greatly expeditescataract surgery. At this point, the surgeon now hassubstantial control of the surgery. I often force part ofthe lens bulk into the posterior chamber, therebyallowing phacoemulsification in the iris plane andaway from the corneal endothelium. This also forcesthe posterior capsule back and out of the way of pha-coemulsification. Following removal of this massivecortex and nucleus, the irrigation/aspiration hand-piece may be used to remove any residual lens cortexif needed. A clean, discrete Fugo Blade capsulotomymargin may be seen at the end of this procedure (Fig5). The stable capsule rim of the PhacoXcap procedureallows for a stable fixation of IOL haptics and excel-lent centration of the IOL (Fig 6).

DiscussionNew technology often calls for a refinement in surgi-cal skills. This was seen when surgeons converted

ANN OPHTHALMOL. 2002;34(1) 13

Fig 1.—Fugo Blade™ capsulotomy unit includes an electronic console, an activationfoot switch, and an ergonomic handpiece.

Fig 2.—Ultrahigh magnification view of the Fugo Blade™ incising tip (×50). Left: Theinactivated incising tip of the Fugo Blade at the end of the tip cannula appears likea small, thin hair. Right: The activated incising tip of the Fugo Blade focuses a low-power electromagnetic field into a 50-µm column around the incising filament, there-by causing the molecules in the 50-µm column to emit light.

Fig 3.—The Fugo Blade™ creates an anterior capsulotomy as per the protocol of thePhacoXcap™ procedure. The incising tip is seen under the upper left portion of the irisand is incising capsule in that region.

from intracapsular cataract surgery to extracapsularcataract surgery, then again when we converted fromextracapsular surgery to phacoemulsification. TheFugo Blade again provides another paradigm shift incataract surgery.8 The advantages of this unit offerpowerful capabilities to the cataract surgeon. Howev-er, a Fugo Blade capsulotomy is not the same as acapsulorhexis.9 Therefore, surgeons must employtechniques that complement the advantages of thisnew technology. The PhacoXcap technique combinesthe ease of standard extracapsular cataract surgerywith the closed-system safety of phacoemulsifica-

tion. The PhacoXcap procedure is made possible bythe unique cutting precision of the Fugo Blade. Thelack of need for red reflex creates an immense num-ber of possibilities, including capsulotomies undermiotic pupils.10

The major goal of cataract surgery should beimproved patient safety.11 In the author’s experience,PhacoXcap not only provides improved patient safetybut also produces greater surgeon control oversurgery as well as greatly reduced surgical time inboth mature cataracts and average cataracts. By mov-ing the cortex and nucleus in one piece quickly andeasily through the capsulotomy and into the anteriorchamber, the PhacoXcap technique with the FugoBlade offers powerful advantages over classicapproaches to cataract surgery.

References1. Fugo, RJ, DelCampo, DM. The Fugo Blade™: the next step after

capsulorhexis. Ann Ophthalmol. 2001;33,1:12–20.2. American College of Eye Surgeons Web site. Available at:

http://www.aces-abes.org/physician_index.htm.3. Kronemyer B. Fugo Blade uses low-level energy to create anterior

capsulotomy. Ocular Surg News. 2000;18,21:45–46.4. Sabbagh LB. The leading edge: harnessing electrons for a faster,

smarter incision. Eyeworld. April 1998;3:88.5. Winn CW. Broad applications seen for electrosurgical instrument.

Ocular Surg News. 2001;19(11):45–46.6. Roy FH. Course for Fugo Blade is enlightening, surgeon says.

Ocular Surg News. 2001;(19)17:35–38.7. Samalonis LB. Improving capsulotomies. Eyeworld. 2001;6(2):42–

44.8. Sabbagh LB. The never ending quest: creating a better way to

remove the lens. Eyeworld. 1998;3(4):50–53.9. Kent C. Plasma capsulotomy. Ophthalmic Manage. 2001;5(8):72–

73.10. Winn MC. Broad applications seen for plasma blade. Ocular Surg

News. Asia Pacific ed. 2001;12(8):1–5.11. Kellan R, Fugo RJ. Device increases safety, efficiency of cataract

surgery. Ophthalmol Times. 2000;25(22):7–9.

ANN OPHTHALMOL. 2002;34(1)14

Fig 5.—Lens bag is ready for implantation of an intraocular lens during a PhacoX-cap™ procedure. The healthy-appearing Fugo Blade™ capsulotomy rim is especiallyvisible immediately inside the left half of the pupil.

Fig 6.—Lens implantation in PhacoXcap™ cataract surgery. On left side, a siliconeintraocular lens (IOL) is being dialed into a healthy PhacoXcap capsular bag. On rightside, there is perfect centration of an IOL in the PhacoXcap lens bag.

Fig 4.—PhacoXcap™ procedure. Upper left: Following an 8-mm Fugo Blade™ capsu-lotomy and hydrodissection, the phaco tip is imbedded into the nucleus and gentlyrocks the entire cortex and nucleus back and forth. Upper right: Still impaling thenucleus, the phaco tip is used to lift the cortex and nucleus as a single piece out ofthe lens bag. Lower left: Phacoemulsification of the cortex and nucleus in iris plane.Lower right: Minimal cortex remains at the end of phacoemulsification.