Eyeworld

OCT 2016

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: http://digital.eyeworld.org/i/733437

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60 October 2016 by Jack Abrams, MD EW REFRACTIVE Using the femtosecond laser to treat a retinal disorder Postop day 1 of a patient with the Implantable Miniature Telescope Why I've chosen to use the femtosecond laser for Implantable Miniature Telescope surgery F emtosecond lasers for cata- ract surgery are beginning to play a more important role for anterior segment surgeons—and evidence is continuing to emerge that these devices are giving us a more ac- curate capsulorhexis than can be performed manually. This, in turn, is making our already safe surgeries that much safer. At our practice, we've been using the LenSx laser (Alcon, Fort Worth, Texas) with our cataract patients for more than 4 years. But it wasn't until recently we began to explore the technology's benefits to help other patients. Take, for example, patients who are referred to us with end-stage age-related macular degeneration. These patients typically have very poor vision—around 20/800—and until recently, had limited options to help provide improved functional vision. They were typically limited to low vision aids to help cope with the tasks of daily living, but these do not provide improved vision. Today, the Implantable Miniature Telescope (IMT, VisionCare, Saratoga, Califor- nia) is available for these severely visually compromised advanced AMD patients, and I think using the femtosecond laser will be an import- ant component of the surgery. The IMT is just a cataract surgery with a telescope on the lens. Its implanta- tion, however, mandates a bit more finesse as the IMT is not foldable and cannot be implanted through a small incision. Why use a femtosecond laser One of the keys to a successful IMT surgery is ensuring the device is properly centered within the cap- sule. In my opinion, the only way that we can do that with today's technology reliably and accurately is with the femtosecond laser. The IMT has been designed to return some vision to those with the most severe vision loss, and studies have shown the majority of patients gain at least three lines of best corrected visual acuity. 1–3 Using the femto laser removes some of the inaccuracies that we inherently have with a typical handmade capsulorhexis. Because the IMT needs to be centered during our capsulotomy, we can determine the exact capsule size that will work best. The IMT is an advanced tech- nology, and the femtosecond laser is arguably the most advanced tech- nology to create a capsulorhexis on the market today. I thought combin- ing these two technologies would be great as the patient gets the benefits of both technologies. Adequate dilation is the key In my opinion, implanting the IMT for surgeons who have never performed an extracap is going to be exponentially more difficult. These devices require an 11- or 12-mm incision, can only be implanted in the capsular bag, and mandate a minimum 7-mm diameter capsulor- hexis. Also, the fit of the IMT in the capsular bag means OVD removal is more challenging. To use the LenSx successfully for this procedure, pupils need to be di- lated beyond 7 mm. We can achieve that through the use of phenyleph- rine 10%, or we can use pledgets to give us the maximum dilation. Unfortunately, some patients do not dilate to the minimum needed for the LenSx; if that occurs I'm com- fortable enough with the surgical technique to revert to manual capsu- lorhexis. How I perform the surgery Although we've achieved adequate dilation and the laser touches the patient's eye, occasionally miosis can occur. What has impressed me about the IMT is that a smaller cap- sulorhexis—6.5 mm or even as small as 6 mm—can still work, although that is not recommended. We have found that a smaller capsulorhexis can accommodate the implant, and the accuracy of the laser allows supe- rior placement of the IMT. There are a few pearls for IMT implantation with the femtosecond laser. First, ensure you have good

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