September 07, 2018
4 min read

Automated capsulotomy system offers affordable advantages for premium procedures

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The Zepto capsulotomy system offers surgeons the opportunity to perform consistent, precise, safe capsulotomies at an accessible cost. It also is easy to use and helps surgeons safely address difficult cases.

“Our site was involved in the FDA trial for approval of the device. I had the chance to see it in action through the trial and to see it adopted soon after in our practice. I have personally performed close to 50 cases, and our group altogether has performed over 1,000,” Russell Swan, MD, told Ocular Surgery News.

There are two main areas in which the Zepto (Mynosys Cellular Devices) is most beneficial and most frequently used, he said. One is refractive cataract surgery, in which premium IOL centration is crucial.

“With the Zepto, you can be sure that your capsulotomy is perfectly circular and centered on the visual axis,” Swan said.

The other main indication is for challenging cases.

Russell Swan

“The Argentinian flag sign, which is a real concern in white cataracts, is completely neutralized with the Zepto. In these cases, Zepto takes 0.4 milliseconds while the femtosecond laser takes a couple of seconds to do a capsulotomy. It is really fantastic for these challenging cases,” he said.

Pearls for safe performance

The cutting element of Zepto is a foldable nitinol ring enclosed in a silicone suction cup. It is inserted in the eye utilizing a retractable pushrod that connects the ring with a console. The console generates suction and then brief electrical pulses to create the capsulotomy.

“The ring folds and unfolds much like an IOL and can be inserted through a very small incision. It cuts very rapidly a perfectly round capsulotomy. If you look at the edge with a high-power electron microscope, you can see that it is smooth and strong, and certainly compares favorably with manual but also with femto capsulotomy,” Steven R. Sarkisian Jr., MD, said.

The learning curve is short, only two to five cases, and in his first 30 eyes, Sarkisian had no incomplete capsulotomies.

“I learned early that in order to achieve this you have to wait for the suction to reach its absolute maximum. Incomplete capsulotomies with Zepto are mainly due to energizing the ring prior to achieving maximum suction,” he said.

Swan recommended making sure that suction is fully and evenly applied, with the silicone flange well spread and resting over the capsule.

“If any small portion of the silicone skirt folds under, you can get an incomplete capsulotomy in the area where the nitinol ring does not adhere to the capsule. This is one thing to watch out for. The same problem occurs when the pushrod that is used for insertion is not fully retracted and rests in the neck of the device. The device may signal that you have achieved full suction, but suction will be partial because the neck is occluded,” he said.


His advice to new Zepto adopters is to stick to the “Goldilocks principle,” starting with cases that are just right.

“Not too deep a chamber, not too shallow, not too small a pupil and so on. Just a nice case to get going. You can use the device with small pupils and in difficult situations, but having a normal eye and being comfortable with the mechanics and the various steps of the procedure are important initially,” Swan said.

The learning curve for surgery is short, but the learning curve for efficiency for the OR staff might take a little longer, around 10 to 15 cases, depending on how consistently the procedure is used.

“This is mainly for the staff to feel comfortable setting the device up correctly and integrating it smoothly into your cataract surgery. Once you have gone through that learning curve, Zepto is more efficient than manual capsulotomy,” he said.

Alternative or addition to femtosecond laser

The femtosecond laser has improved the performance of surgeons and the level of refractive excellence they can offer, but it requires additional time and space. The Zepto does not require a separate procedure in a separate room and only adds a short time to the overall procedure.

Steven R. Sarkisian Jr.

“You don’t have the advantage of lens fragmentation, but you can offer patients a premium option at a lower price. In the U.S., we value premium services a lot, and with multifocal and toric lenses, I offer the LenSx femtosecond laser technology and ORA technology (both Alcon). However, in cases where I implant a toric lens and therefore don’t need to do any relaxing incision for astigmatism and in cases where phaco fragmentation is less necessary, I prefer to use the Zepto,” Sarkisian said.

In addition, small eyes with a narrow distance between the eyelids may be unsuitable for the large suction cup of the LenSx, and Zepto may be a better option in these cases.

“Cost is a fraction of what is required for a femtosecond procedure. Both the capital cost and the cost per procedure are minimal, and yet the patient can be offered a premium option. On the other hand, if you think in terms of investment, there is only one thing you can do with the Zepto, while the femtosecond laser has multiple functions,” he said.

Having both technologies in a clinic is ideal for offering premium options at different prices in different cases, Sarkisian said.


Present and future uses

The per-use fee due to the disposable parts of the device is a limitation to the application of Zepto for routine cases, Swan said.

“It is up to individual surgeons to decide the value of Zepto. In my practice, we feel that it is worth it for complex cases and for refractive cases,” he said.

“There are cases where I use it preferentially, such as difficult capsulorrhexis, loose zonules, very dense cataract and visibility issues. In these cases, the Zepto may offer a significant safety advantage,” Sarkisian said.

Future applications could be for pediatric cataract surgery, in which capsulotomy is challenging, and for posterior capsulotomy after the IOL is in place, Swan said.

“It could also have a role for some accommodative lenses and for bag-in-the-lens techniques that require very precise capsulotomies. I think that there is potential for continuous growth and new applications,” he said. – by Michela Cimberle

Disclosures: Sarkisian reports he is a consultant for Alcon, Allergan, Beaver-Visitec International, Glaukos, Katena Products, New World Medical, Omeros, Santen and Sight Sciences. Swan reports he is a consultant for Alcon, Glaukos and Equinox.