femtosecond laser assisted cataract surgery for laser assisted cataract surgery for cataract and rle

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Femtosecond laser assisted cataract surgery for cataract

and rle

Prof.Dr.Mahmut Kakalolu

Kakalolu Eye Hospital

Izmir, Turkey

june 2016

No financial disclosure

Cataract surgery decreases mortality rate

..United States Medicare patients with cataract, those who underwent cataract surgery had 30% reduced mortality compared with those who did not undergo surgery.

Tseng VL,Yu F, PhD,1,3 Lum F, Coleman AL., Cataract Surgery and Mortality in the United States Medicare Population.Ophthalmology 2016;123:1019-1026

Cataract surgery is the most common operation

Europe average 10,000 per million

450,000 cataract operations in Turkey About 6000 per million

Today many RLE with multifocals

All patients expect perfect results

How do we make it better and safer?

Asclepion-Meditec Phacolase Er:YAG

Paradigm Photon Nd:YAG

WaveLight Adagio Er:YAG

erbium:YAG laser, Nd:YAG laser (2000)

ARC Laser's Dodick Laser Photolysis


Femtosecond laser

1053nm(near IR) spectrum

Focus 3m Spot size

Ultrashort pulse10-15 sec a Millionth of a Billionth of a sec

No collateral damage

Laser Energy is absorbed by tissue,

causing plasma formation

and molecules expand

resulting cavitation bubbles

and tissue separation

Femtolaser in ophthalmology:

Flap creation: LASIK

Lenticule extraction: SMILE

Channel for ICR

Corneal graft


Arcuate incisions



Future use of Femtolaser in ophthalmology:

Treatment of tractional vitreous attachments.

Reversing presbyopia.

Refractive index shaping.

Corneal collagen crosslinking (CXL).

Reversing cataract. Lubatschowski H. Applications of the Femtosecond Laser A new era of ophthalmology. CRST Europe 2012 feb. 52-54

Problems with conventional phaco

Difficult learning curve

Dependent of the surgeons dexterity

For perfect results all steps must be within acceptable tolerances

Most complications caused by the surgeon, 10X LASIK

Many manual steps which cannot be executed with reproducible precision and predictability.

Efficacy : More predictable and accurate capsulotomy

More consistent corneal incision construction

Better refractive results

Safety : Less ultrasound energy

Less risk of capsule tears

Less incision leakage and astigmatism

Potential benefits of Femto cataract surgery

Current FS platforms

LenSx (Alcon Lab., USA)

Catalys (Optimedica Corp.,USA)

LensAr (LensAr Inc., USA)

Victus (Technolas, Germany; Bausch&Lomb, USA)

Ziemer Femto LDV Z (Ziemer Ophthalmic System AG,USA)

1.Catalys: Liquid optics, nonapplanating

2.LensAR: Fluid interface, nonapplanating

3.LenSx: Curved lens, applanating

4.Victus: Dual modality

5.Ziemer: Liquid interface


1.Catalys: 3D OCT

2.LensAR: Confocal Structured Illumination (3D-CSI)

3.LenSx: 3D OCT

4.Victus: 3D OCT

5.Ziemer: OCT


LenSx Laser

Touch screen Graphic User Interface

Real-time video imaging for 3D visualization

True image-guided surgical planning

Sterile or unsterile.

Can be located in the same room or different rooms.

Corneal incisions


Laser lens fragmentation

Arcuate incisions

Lasik flaps (not yet available)

Applications of LenSx

Patient selection General

Can lie flat and still

Back problems


Inform Subconjunctival hemorrhage

Check Lids

Pupil dilation

Anterior capsule

Cataract type


Docking Patient lies flat

to PI

Bubbles in interface or suction loss:

Undock and dock again

Suction loss during femto:

proceed with manual phaco

Less induced astigmatism

Trapezoid incision

Stepped incision

Self sealing

Less wound leak

Arcuate incisions

Excellent reproducibility Masket S, et al. Femtosecond laser-assisted cataract incisions: architectural

stability and reproducibility. J Cataract Refract Surg. 2010

Corneal incisions

Exact sizing Stability

Better Effective lens position

Less capsular opacity Stable refraction

Perfect shape Perfect centralization

Less aberration Less phimoses

More capsule strenght Less capsule tear

1. Nagy Z, et al. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009 2. Kranitz K, et al. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011 3. Friedman NJ, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011 4.Dick HB, et al. Intraocular lens fixated in the anterior capsulotomy created in the line of sight by a femtosecond laser. J Refract Surg. 2014



Manual CCC Laser CCC

Deviation Diameter: 337 258 m Circle: %20

Deviation Diameter: 29 26 m Circle: % 6

Friedman NJ, et al. Femtosecond laser capsulotomy J Cataract Refract Surg, 2011.

Optimal CCC for IOL:

4.8mm to 5.2mm

Prefemto Pupil diameter 1.5mm larger than CCC

To Prevent Pupil constriction after femto:

Preop NSAI, Cyclopentolate, Neosynephrine Keep interval between femto and phaco short Repeat Neonynephrine after Femto Adrenaline in BSS First cases 40% now less than 15%

Pupil size

Watch for Intumescence


Always stain capsule

Prefemto: Iris hooks or Malyugin

ring Benefit to patient


If pupil too small for minimal CCC , manual phaco maybe safer

Post femto: Adrenaline Viscodilation Iris hooks Malyugin ring

What to do if you cannot do femto ?

Small Pupil

Gently tap and tilt the nucleus

Decompress air bubbles from behind the lens

Gently inject BSS

See bubbles come forward

Aggressive, rapid, hydrodissection may cause posterior capsule rupture


o Divide&conquer, chop

o Dont be discouraged during the learning curve

o Our total femto procedure duration is now 10m vs 19m during the early period


Harder cataracts cylinder pattern facilitate central debulking

Matrix pattern

Lens fragmentation

Effective phaco time (EPT) and cumulative dispersive energy

(CDE) reduced1,5

Central corneal thickness reduced, less endothelial cell loss6

Some studies indicate less early macular thickness after


5. Conrad-Hengerer I, et al. Effect of femtosecond laser fragmentation on effective phacoemulsification time in cataract surgery. J Refract Surg. 2012 6. Takacs AI, et al. Central corneal volume and endothelial cell count following femtosec-ond laser-assisted refractive cataract surgery compared to conventional phacoemulsification. J Refract Surg. 2012

During Femto CCC laser cuts 300m

circular cortex

This is flush with the CCC edge

Hydrodissection may not be possible between the capsule and the layer of cortex

In theory this is a safety zone

With some experience this is not an issue and all cortex can be removed easily

Cortex removal

Arcuate Relaxing incisions:

80% depth

Opened during surgery

Opened later

Nomograms are being developed

Long term efficacy to be determined

For refractive cataract and RLE cases toric IOL is the better option


Preop. Data: - CDVA: 0.5/0.5 - Otoref.:

- OD: +1.25 +6.25x175 - OS: +3.75-5.75x110

- Corneal ast.: - OD 4.75 D - OS: 5.25 D

- OD: Femto RLE+ mono toric - OS: Femto RLE+ mono toric+ AK

Postop. Data: - UDVA: 0.7-0.8 / 0.7 - Otoref.: OD: +2.00-2.75x90 OS: +0.75-0.75x115

Asena BS, Kaskaloglu M. Laser-assisted cataract surgery: softlens assisted interface(SoftFit) versus direct contact interface. Eur J Ophthalmol 2016; 26(3): 242 - 247

Kaskaloglu Eye Hospital Izmir

February 2013-February 2016

670 eyes

No laser complications Incomplete CCC in 62 eyes

1 anterior capsule tear

1 posterior capsule break

Average operation time 14 minutes

We are still in the early phase of this advanced technology

We already know that It can do CCC better than us

May lead to better refractive outcome

It can lower the phaco time

May reduce endothelial cell loss

Planned incision architecture

Less induced astigmatism



Narrow palpebral aperture, deep orbit, high brow

Posture problems

Corneal opacities

Small pupil, synechia

White, advanced cataract

Femto laser is a tool

We will learn how to maximize this


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