When it comes to buying a phacoemulsification machine, unless the surgeons are also facility owners, administrators and physicians tend to take very different approaches to deciding which machine to buy. Here are the seven factors you need to consider to help you decide which machine (see "Your Phaco Machine Choices") is right for your facility.

The phaco machine you choose should be easy for your staff to use and understand.

"The software should tell you how to hook tubing up, " says Herbert "Cam" Cameron, the president and founder of American Optisurgical, Inc. (AOI). "It should tell you if you have fluidic failure. You also want to make sure that tubing, fluidics settings and the IV pole for the bottle are easy to use."

Mr. Cameron suggests looking for a machine with easily programmed presets so staff can quickly learn how to use it. "If you have a turnover in staff, it should be easy to pick up," says Mr. Cameron. "The doctor doesn't want the staff saying 'Hold on, I can't do this.' "

You should be able to trouble-shoot if a problem arises. "Often, machines that do it all for you are so self-contained they are difficult to diagnose," says Gina Stancel, HCRM, CST, COA, administrator for the Eye Centers of Florida in Fort Myers. "Memorization is not the goal, learning the machine is."

The machine's fluidics - the inflow (irrigation) and outflow (vacuum) of balanced salt solution (BSS) to and from the eye - are as important as the phacoemulsification itself. "If you don't have enough inflow, or you have too much outflow, you're going to have problems," says Mr. Cameron. "If your fluidics aren't right, none of the other things will matter."

Fluidics control intraocular pressure; if pressure in the eye fluctuates, you get "bounce," which puts the capsule in jeopardy of being caught by the phaco tip. Most phaco systems employ peristaltic pumps, which stop and start according to the doctor's use of the foot pedal. Bausch & Lomb's Millennium also offers a venturi pump system, which allows for more constant flow.

"The newer goal is to keep actual phaco time to a minimum through high-vacuum tubing," says Ms. Stancel. "This lets the surgeon use more suction and less cavitation, which is disruptive to the endothelial cells. It means the machine needs to perform and respond well using a high-vac setting."

A trial or demo will help your surgeons determine whether they like the fluidics, says Julie Macuch, RN, a co-director at Plymouth Laser and Surgical Center in Plymouth, Mass.

To avoid corneal burns, firms have tried to make the phaco tip run "cooler." That is, the tip's ultrasound frequency is lower, or pulses are used instead of steady power. "The 'burst' method uses less phaco time and the tip runs cooler," says Mr. Cameron. The lower the frequency or the less often energy is in the eye, the less likely the cornea is to be burned, causing cornea shrinkage and making wound closure difficult.

Another tip feature to consider is re-usable versus disposable. And several tip sizes and angles should be available to accommodate surgeons and case variety, says Ms. Stancel.

Surgeon preference shouldn't necessarily be the No. 1 factor in your decision, but it should be in the top four. "It's like a race car - every driver feels comfortable in a different one," says Mr. Cameron. "If you buy a machine and nobody likes it, you can't bring any doctors into your facility."

Yes, it's that simple, says Ms. Macuch: "They're the ones doing the surgery. They have to be comfortable."

The features that play into a surgeon's comfort include the ergonomics and weight of the handpiece and the functionality of the foot pedal; some surgeons prefer a simple pedal that controls irrigation, aspiration and phacoemulsification; others want to change program pre-sets through the pedal.

In addition, says Ms. Stancel, "Response time of the machine is very important, as is the ability to easily change modes during a procedure. A remote the scrub tech can control helps."

Surgeon comfort can be determined in a demo or trial but, if you're buying for a new facility, this can be tricky. Mr. Cameron suggests talking to as many doctors as possible to help you decide.

Dollars and cents are the first things an administrator sees regarding any purchase; phaco machines are no different.

On top of the outlay for the machine, there are these factors: Are the tubing, phaco tips and sleeves re-usable or disposable? How much will it cost to reprocess re-usables? Can you get financing? At what rate? Do you want to bundle your cataract surgery equipment (phaco machine, IOLs, viscoelastics and tubing)?

"Some might not want to go to Company A for IOLs, to Company B for viscoelastic, to Company C for the phaco machine," says Mr. Cameron. "It can be a hassle."

While Mr. Cameron cautions that not all bundling deals may be as good as they seem, he says you shouldn't be afraid to deal with the companies. "The more surgeries you do, the more leverage you usually have," he says. "If you're doing 1,000 a year, the company may charge you $20 for the tubing set. If you're only doing a few a month, they may charge you $145. That's a lot if your mach-ine uses disposable tubing."

You should also find out how many bottles of BSS the mach-ine uses. "I get at least three cases out of my outflow bottle, but I can use my reflux bottle all day," says Ms. Macuch. "A surgery center I know of uses two new bottles for every case because of its phaco machine. That seems like a waste."

Figuring out the cost-per-case involves some research and some estimation, but you'll know the cost of your machine - not just what you paid for it.

Take a long, hard look at your OR and storage areas. Some machines, such as the new Alcon Infiniti or B&L's Millennium, have large footprints. Others, such as AOI's Horizon or AMO's new Sovereign Compact, are smaller and portable. A large machine may be better suited for an ophthalmology-focused facility that will be keeping the phaco machine in the OR and will be using it often. A smaller machine may be best for a multi-specialty facility in which it needs to be moved often.

If your phaco machine goes down, delaying or canceling procedures could cost your facility a lot of money.

"You have to have a responsive rep," says Ms. Macuch. "It doesn't happen often, but you need to have confidence that if you have a problem, you can pick up the phone and someone is going to help."

You need to consider how the machine is serviced (Do you need to ship it out or have a repairperson come in?) and how quickly it can be serviced - especially when the machine is no longer under warranty.

"Modules are the most cost-effective and convenient method of repair," says Ms. Stancel. "Simply removing the module that is malfunctioning and having a replacement sent overnight saves time and money in either waiting for a repairperson or mailing back the entire machine."

But, as mentioned earlier, your staff does need to be able to understand the machine well enough to troubleshoot and know which module is malfunctioning. In addition, you should talk to other end users to find out their experiences with the companies you're considering buying from. "If you call at 2 p.m. to order a machine, when are they going to ship it?" asks Mr. Cameron. "Do you want to hear a phone system or talk to a real person? Do you want to be able to fax in your order?"

Decision time
If you've done your research and demos and talked to your surgeons, and you find that you're still unsure about which phaco machine to buy, Ms. Stancel has this advice: "Really, with the exception of peristaltic versus venturi, many of the machines are alike. It comes down to ease of use on the surgeons' part and expense of supplies."