September 2015

 

CATARACT

 

How has the femtosecond laser changed your cataract surgical technique?


by Lauren Lipuma EyeWorld Staff Writer

 
     

Three surgeons share how their technique has changed since incorporating the laser into practice

Whether for correcting astigmatism, removing the nucleus, or optimizing surgical efficiency, surgeons have to adopt a slightly different technique for femtosecond laser- assisted cataract surgery than for manual phaco. Most surgeons agree that there is a learning curve for the first 100 or so cases, and for physicians just starting out with this procedure, it can be helpful to know what unexpected issues may come up during surgery. EyeWorld asked laser cataract surgery pioneers Robert J. Cionni, MD, medical director, The Eye Institute of Utah, Salt Lake City; Zoltan Nagy, MD, clinical professor of ophthalmology, Semmelweis University, Budapest, Hungary; and Jonathan Talamo, MD, director, Massachusetts Eye and Ear Infirmary Waltham, Waltham, Mass., how their technique has changed since incorporating the laser into practice. Here, in their own words, Drs. Cionni, Nagy, and Talamo describe what makes laser cataract surgery different from manual.

Robert Cionni, MD

Since the lens is already fragmented, I rarely need to utilize a second intraocular instrument for lens manipulation.

Robert J. Cionni, MD

Since the lens is already fragmented, I rarely need to utilize a second intraocular instrument for lens manipulation. The improved fluidics of the Centurion Vision System (Alcon, Fort Worth, Texas) result in a more efficient procedure with less cumulative dissipated energy (CDE) and less fluid moved through the eye, typically around 20 cc instead of the 50100 cc we saw before. Since we are not putting instruments in and out of the side port incision, this incision seals much more easily as well.

The corneal arcuate incisions are much more precise with a more predictable effect than any manual incision Ive ever made. I prefer to limit cylinder reduction with arcuate incisions to 2 D or less, using a toric IOL for more significant astigmatism management.

Zoltan Nagy, MD

During hydrodissection, the lens should be moved up and down and must be rotated. This is the so-called rock and roll technique. With this method, I never had any rupture of the posterior capsule.

Zoltan Nagy, MD

The surgeon must have a plan before entering the OR. Therefore, I see every patient in the morning before surgery and I decide what to do. Laser pretreatment is very short, so the surgeon should check all steps before starting the laser pedal. The second most important thing to do for those who start with this technology is to follow the contour of the capsulotomy to avoid anterior tears. The next important step is the gentle hydrodissection to allow the intralenticular gas bubble to leave the eye through the anterior chamber without causing rupture of the posterior capsule. During hydrodissection, the lens should be moved up and down and must be rotated. This is the so-called rock and roll technique. With this method, I never had any rupture of the posterior capsule. A special chopper is needed to fragment the crystalline lens, and from then on, the procedure is similar to manual phacoemulsification. During laser cataract surgery, a larger epinucleus may stay, which has a protective role for the posterior capsule. During irrigation/aspiration (I/A), the surgeon should control this.

Jonathan Talamo, MD

What Ill typically do is Ill start my day by treating 2 patients. One will immediately go into surgery and the other will wait and go in when the first ones done. So the delay is no more than 20 minutes.

Jonathan Talamo, MD

Because you already have a cut in the anterior capsule, you have to be very careful not to destabilize the chamber when you enter the eye. In the unlikely event you have a residual attachment between the capsular disc and the peripheral capsule, if you put uncontrolled tension on that area, you could have a tear in the capsule. So Ill enter very carefully and inflate with viscoelastic to minimize any chamber instability. Then Ill proceed with whats called a dimple-down maneuver, where Ill use a cystotome, or more typically Utrata forceps, to remove the capsule; I will push down on the middle of the capsular disc to identify any tension striae where there may be adhesions. Once Im certain that there are no adhesions, Ill proceed with removal of the capsular disc. I tend not to inflate the anterior chamber as much as I otherwise would because when I go to hydrodissect, I want room for gas bubbles to come forward around the lens. If it seems that the gas generation from treating the lens has remained trapped in the capsular bag and the capsular bag is under tension, I enter the eye with my phaco probe and a second instrument and carefully push apart the cut segments of the lens to allow the gas bubbles to come forward and decompress the bag before I do further manipulation to free the nucleus. Instead of requiring hydrodissection with balanced salt solution, sometimes theres either no or very little hydrodissection required. I will assess this situation before I proceed with the full hydrodissection by rocking the lens back and forth and seeing if it rotates freely.

When it comes to removing cortex, you dont have strands of cortex sticking out beyond the edge of the capsule because theyve been cut with the laser. I use a curved I/A tip that lets me comfortably put the aspiration port right up under the capsule, and then tangentially (diagonally) engage until I have cortex and strip it in a circumferential manner. I prefer bimanual I/A for this but an angled/curved coaxial I/A tip also works well.

It is clear that you can perform a laser treatment and then wait a little while before you take a patient into the operating room. But if you treat a patient with the laser and you leave them waiting for an hour or 2, cytokines and inflammatory mediators can be released into the eye and the pupil can constrict, and that can be more difficult to keep dilated during the procedure. So that is a challengeto make sure that the timing of the laser pretreatment and the completion of the surgery are appropriately sequenced. What Ill typically do is Ill start my day by treating 2 patients. One will immediately go into surgery and the other will wait and go in when the first ones done, or go into a second room down the hall. So the delay is no more than 20 minutes.

Editors note: Dr. Cionni has financial interests with Alcon. Dr. Talamo has financial interests with Abbott Medical Optics (Abbott Park, Ill.). Dr. Nagy has no financial interests related to this article.

Contact information

Cionni: 801-266-2283
Nagy: nz@szem1.sote.hu
Talamo: Jonathan_Talamo@meei.harvard.edu

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Is femtosecond laser-assisted cataract surgery safer than conventional cataract surgery? by Ellen Stodola EyeWorld Senior Staff Writer

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