G. BAÏKOFF MD, Ch. AUBERTG. BAÏKOFF MD, Ch. AUBERTThe author is a consultant for Carl Zeiss MeditecThe author is a consultant for Carl Zeiss Meditec

Clinique Monticelli – Marseille - FranceClinique Monticelli – Marseille - Franceg.baik.opht@wanadoo.fr

The ZEISS VISUMAX ™ FEMTOSECOND LASER obtained the CE mark for corneal grafts in May 2008. Graft software has a high frequency pulse rate (200 kHz), with very small spots (2 to 3 µm), the energy delivered is to the scale of the nano Joule

A retrospective study was carried out on 58 eyes having had either MANUAL/MICROKERATOME DSEK (41) or FEMTO DSEK (17).

Over the last 8 months the femtosecond laser has been used for most of the new cases.

Even if the statistic method needs perfecting, analysis of our results reveals a trend

The Visumax femtosecond laser allows a three dimensional cut of the corneal tissue. Very precise focus, high frequency (200 KHz) and minimum energy enable very smooth cuts due to extremely tight spot spacing (2 - 3 µm).

Deep cuts (up to 800 µm) parallel to the cornea’s epithelial surface give a thin endothelial graft with almost parallel flaps, unlike the microkeratome where depth of cut is rarely more than 350 µm to create a anterior lenticle with thin edges and a thick posterior concave endothelial graft.

MICROKERATOME - MENISCUS CUT - MAXIMUM DEPTH : MICROKERATOME - MENISCUS CUT - MAXIMUM DEPTH : 200/300 µm200/300 µm

DSEK - ALTK

VISUMAX FEMTOLASER - PARALLEL CUT -VISUMAX FEMTOLASER - PARALLEL CUT - MAXIMUM DEPTH MAXIMUM DEPTH 700 µm 700 µm

NOTICE THE DIFFERENCE OF DONOR’S SHAPE : KERATOME vs FEMTONOTICE THE DIFFERENCE OF DONOR’S SHAPE : KERATOME vs FEMTO

DSEK - FEMTO

FEMTO DSEKsFEMTO DSEKs

1st SURGERY JULY 20081st SURGERY JULY 2008LAST SURGERY FEBRUARY 2009LAST SURGERY FEBRUARY 2009

CASES 17 CASES 17 MALE 6 FEMALE 11MALE 6 FEMALE 11 MEAN AGE 63 RANGE 34 - 83MEAN AGE 63 RANGE 34 - 83 MEAN F.UP 2.6 months RANGE: 2 weeks – 6 MEAN F.UP 2.6 months RANGE: 2 weeks – 6 monthsmonths

PSEUDOPHAKIC CORNEAL OEDEMA : 9PSEUDOPHAKIC CORNEAL OEDEMA : 9 IOL EXCHANGE : 4 IOL EXCHANGE : 4 FUCHS DYSTROPHY : 5FUCHS DYSTROPHY : 5 TRIPLE PROCEDURE (KPE, IOL, DSEK) : 4TRIPLE PROCEDURE (KPE, IOL, DSEK) : 4 NORMAL PREOP MACULA : 4NORMAL PREOP MACULA : 4 POSTERIOR POLE PATHOLOGY : 6POSTERIOR POLE PATHOLOGY : 6 UNKNOWN PREOP MACULAR STATUS : 7UNKNOWN PREOP MACULAR STATUS : 7

MANUAL & MICROKERATOME DSEKsMANUAL & MICROKERATOME DSEKs

1st SURGERY NOVEMBER 20071st SURGERY NOVEMBER 2007LAST SURGERY FEBRUARY 2009LAST SURGERY FEBRUARY 2009

CASES 41CASES 41 MALE 18 FEMALE 23MALE 18 FEMALE 23 MEAN AGE 72 RANGE 46 - 89MEAN AGE 72 RANGE 46 - 89 MEAN F.UP 3.4 months RANGE 2 weeks – MEAN F.UP 3.4 months RANGE 2 weeks – 14 months14 months

PSEUDOPHAKIC CORNEAL OEDEMA : 18PSEUDOPHAKIC CORNEAL OEDEMA : 18 IOL EXCHANGE : 6IOL EXCHANGE : 6 FUCHS DYSTROPHY : 19FUCHS DYSTROPHY : 19 TRIPLE PROCEDURE (KPE, IOL, DSEK) : 14TRIPLE PROCEDURE (KPE, IOL, DSEK) : 14 NORMAL PREOP MACULA : 12NORMAL PREOP MACULA : 12 POSTERIOR POLE PATHOLOGY : 7POSTERIOR POLE PATHOLOGY : 7 UNKNOWN PREOP MACULAR STATUS : 22UNKNOWN PREOP MACULAR STATUS : 22

DAY 1 DAY 1 RECIPIENT 631 RECIPIENT 631 µm µm ENDOTH. 163 ENDOTH. 163 µmµm

DAY 7 DAY 7 RECIPIENT 536 RECIPIENT 536 µm ENDOTH. 134 µm ENDOTH. 134 µmµm

DAY 60 DAY 60 RECIPIENT 460 RECIPIENT 460 µmµm ENDOTH. 83 µmENDOTH. 83 µm

RECOVERY OF ENDOTHELIUM FUNCTIONRECOVERY OF ENDOTHELIUM FUNCTION

ENDOTHELIUM CELL COUNTENDOTHELIUM CELL COUNTFEMTO vs MANUALFEMTO vs MANUAL

ENDOTHELIAL C. DENSITY ENDOTHELIAL C. DENSITY • 34 MANUAL DSEK : 1389 C / 34 MANUAL DSEK : 1389 C / mm²mm²• 9 FEMTO DSEK : 1738 C / 9 FEMTO DSEK : 1738 C / mm²mm²

AVERAGE GRAFT THICKNESSAVERAGE GRAFT THICKNESS• 34 MANUAL DSEK : 155 34 MANUAL DSEK : 155 µmµm• 9 FEMTO DSEK : 9 FEMTO DSEK : 103 µm103 µm

(excluding the 1st case)(excluding the 1st case)

RECOVERY OF ENDOTHELIUM FUNCTIONRECOVERY OF ENDOTHELIUM FUNCTION9 FEMTO vs 34 MANUAL/KERATOME9 FEMTO vs 34 MANUAL/KERATOME

-  3MONTHS F.UP --  3MONTHS F.UP -

STROMA & DONOR THICKNESSSTROMA & DONOR THICKNESS

ADVANTAGESADVANTAGES

• PRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITYPRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITY• REGULAR GRAFT : SHAPE-THICKNESSREGULAR GRAFT : SHAPE-THICKNESS• WIDE CHOICE OF SETTINGSWIDE CHOICE OF SETTINGS• SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT

DISSECTIONDISSECTION• LESS ENDOTHELIAL CELL LOSSLESS ENDOTHELIAL CELL LOSS

ADVANTAGESADVANTAGES

• PRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITYPRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITY• REGULAR GRAFT : SHAPE-THICKNESSREGULAR GRAFT : SHAPE-THICKNESS• WIDE CHOICE OF SETTINGSWIDE CHOICE OF SETTINGS• SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT

DISSECTIONDISSECTION• LESS ENDOTHELIAL CELL LOSSLESS ENDOTHELIAL CELL LOSS DISADVANTAGESDISADVANTAGES

• COSTLY INVESTISSEMENTCOSTLY INVESTISSEMENT• SURGERY TIME LENGTHENED (TRAINING LEARNING CURVE)SURGERY TIME LENGTHENED (TRAINING LEARNING CURVE)• DEPTH LIMITED BY MINIMUM THICKNESS OF THE CORNEADEPTH LIMITED BY MINIMUM THICKNESS OF THE CORNEA• PRESENTLY ONLY EPITHELIUM PARALLEL CUTS, IMPOSSIBLE TO PRESENTLY ONLY EPITHELIUM PARALLEL CUTS, IMPOSSIBLE TO

MATCH THE CUT WITH THE POSTERIOR PLANE (FLEX?) MATCH THE CUT WITH THE POSTERIOR PLANE (FLEX?)

THE ANATOMICAL RESULTS LOOK VERY SATISFYING IN THE ANATOMICAL RESULTS LOOK VERY SATISFYING IN FAVOR OF THE FEMTO DSEK;FAVOR OF THE FEMTO DSEK;

BUT WE ALSO HAVE TO CONSIDER THE FUNCTIONAL BUT WE ALSO HAVE TO CONSIDER THE FUNCTIONAL RESULTS.RESULTS.

IN OUR TRIALS, THE 3 MONTHS BEST CORRECTED IN OUR TRIALS, THE 3 MONTHS BEST CORRECTED VISUAL ACUITY IS MUCH BETTER IN THE VISUAL ACUITY IS MUCH BETTER IN THE MANUAL/MICROKERATOME DESK SERIES:MANUAL/MICROKERATOME DESK SERIES:

0,38 vs 0,120,38 vs 0,12!!!!!!!!!!

LONGER FOLLOW UP AND FURTHER LONGER FOLLOW UP AND FURTHER TRIALS ARE MANDATORYTRIALS ARE MANDATORY..

g.baik.opht@wanadoo.frg.baik.opht@wanadoo.fr