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Femtosecond LASER ASSIST For Complex Cataracts: PXE and Loose Zonules

Michael J Taravella, MD Director: Cornea and Refractive Surgery

University of Colorado

The author has no financial interest in the material presented

•  The first sign of a complication in cataract surgery is:

DENIAL

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Approach to the patient with a “complex cataract”

•  Small pupil/synechiae •  White Cataract •  Brunescent Cataract •  Phacodenisis

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Be prepared

•  Prepare the patient for: – Longer surgery – A block – Realistic expectations – Review possible complications

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OR preparation

•  Malyughin Ring/Iris Hooks •  CTR (Morcher ®) •  Trypan blue •  Trouble kit: – Scissors, Needle holder, Suture, Glue (Resure) – Vitrectomy set up •  MVR blade •  Familiarity with Pars Plana Incisions

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Femtosecond Lasers and Cataract Surgery

•  Precision Incision – Capsulotomy in particular

•  Astigmatism (LRI) “Femtosecond lasers make routine cases easier,

complex cases routine, and impossible cases possible.”

Juan Batlle

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Factors predisposing to zonular weakness

•  Systemic problems – Marfan’s syndrome – Pseudoexfoliation syndrome

•  Trauma

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Strategies to Address Zonular Dehiscence

•  Low stress capsulotomy – Minimize tangential and centripetal forces if possible

•  Low flow phacoemulsification – Try to decrease turbulence

•  Minimize force used to crack/divide nucleus •  Judicious use of CTR/support rings

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Surgical Pearls

•  Femtosecond laser allows for capsulotomy and nuclear quadrant division to be performed with minimal zonular stress

•  Iris hooks (or flexible capsule retractors) are used to support the capsule throughout the procedure

•  Placement of CTR stabilizes bag and may prevent late dislocation

•  Lens support relies on sulcus haptic position and optic capture

Surgical Pearls

•  Most importantly: Have a willing and ready retina surgeon working

next door!

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Use of Femtosecond Laser-Assisted Cataract Surgery in Complex Cases

POSTER PRESENTATION ASCRS 2014

Beeran Meghpara, MD Richard S. Davidson, MD Michael J. Taravella, MD

Financial Disclosures: Beeran Meghpara, MD and Michael J. Taravella have no financial interests in the subject matter of this poster. Richard S. Davidson, MD is a consultant for Alcon

Purpose

•  To evaluate the utility of femtosecond laser assisted cataract surgery in complex cases

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Methods

•  Retrospective chart review of 17 patients –  Mean age 58 years (range 27 to

81 years) •  LenSx femtosecond laser

(Alcon) assisted complex cataract surgery performed between 2012 and 2013

•  Main outcome measures were complications with the anterior capsulotomy, other surgical complications, and post-operative best corrected visual acuity

Patient Characteristics

Patient Age Cataract Type

10 59 Soft White

11 48 Soft White

12 60 Soft White

13 56 Mature Brunescent

14 75 Mature Brunescent

15 55 Mature, Previously Congenital

16 81 Pseudoexfoliation with phacodonesis

17 27 Central Anterior Capsular Scar

Patient Age Cataract Type

1 51 Dense White

2 50 Dense White

3 75 Dense White

4 55 Dense White

5 53 Dense White Traumatic

6 58 Soft White

7 45 Soft White

8 64 Soft White

9 62 Soft White

Results

•  A successful complete capsulotomy was achieved in 14 of 15 cases. –  Suction loss occurred in one

case resulting in an incomplete capsulotomy

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Figure 4

Ophthalmology 2014 121, 17-24DOI: (10.1016/j.ophtha.2013.08.013) Copyright © 2014 American Academy of Ophthalmology Terms and Conditions

Anterior Capsulotomy Integrity after Femtosecond Laser-Assisted Cataract Surgery  Robin G. Abell, MBBS, Peter E.J. Davies, FRANZCO, David Phelan, BSc, Karsten

Goemann, PhD, Zachary E. McPherson, BMedSci, Brendan J. Vote, FRANZCO  Ophthalmology 

Volume 121, Issue 1, Pages 17-24 (January 2014) DOI: 10.1016/j.ophtha.2013.08.013

Results

•  Lens fragmentation was attempted on four cases

•  A posterior capsular tear occurred during one of these cases on a brunescent lens

•  Two additional cases were complicated by a posterior capsular tear.

•  All patients had a better post-operative best corrected visual acuity compared with pre-operative acuity –  81% of patients with sufficient

follow-up achieved vision of 20/40 or better.

Results Case Cataract Type Pre BCVA Post BCVA LenSx Procedure Complication Comments

1 Dense White HM 20/20 Cap, Nuc, Wounds None

2 Dense White LP 20/20 Cap None

3 Dense White LP 20/40 Cap None 1+ PCO

4 Dense White HM 20/50 Cap, Wounds None

5 Dense White Traumatic LP 20/70 Cap, Wounds PC Tear, ACIOL 2 weeks post PPV for RLF and CME

6 Soft White CF 20/20 Cap, Wounds None

7 Soft White HM 20/20 Cap None

8 Soft White CF 20/40 Cap None

9 Soft White 20/150 20/30 Cap Suction loss Partial capsulotomy

10 Soft White LP 20/40 Cap, Wounds None Paracentral corneal scarring

11 Soft White HM 20/20 Cap, Wounds None

12 Soft White 20/150 20/20 Cap, Nuc, Wounds None

13 Mature Brunescent CF 20/60 Cap, Wounds PC Tear, ACIOL

14 Mature Brunescent HM 20/20 Cap, Wounds None ECCE conversion, very dense lens

15 Mature, Previously Congenital HM 20/250 Cap, Nuc, Wounds PC Tear, SIOL** Amblyopia from congenital posterior polar cataract

16 PXE w/ phacodonesis 20/40 20/20 Cap, Nuc, Wounds None

17 Central Ant Capsular Scar 20/100 20/20 Cap, Wounds None

HM = hand motion, LP = light perception, CF = count fingers, Cap = Anterior Capsulotomy, Nuc = Nucleus Chop, PXE = pseudoexfoliation

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Conclusions

•  The femtosecond laser is an effective tool for creating an anterior capsulotomy in challenging cases.   – Especially useful in safely creating a capsulotomy in

cases with zonular instability and phacodonesis

Contact Information

•  Michael.Taravella@ucdenver.edu