Eyeworld

EW RESIDENTS 52 February 2019 EyeWorld journal club by Christine Bokman, MD, Eric Shieh, MD, and Patrick Lee, MD tional phacoemulsification, high-en- ergy FLACS has been shown to be associated with higher prostaglan- din levels and a different cytokine profile in the aqueous. 2,3 The spike in prostaglandin levels is associated with intraoperative miosis, which hampers surgical exposure, may require the placement of a pupil-ex- panding device, and can make near- ly every step of phacoemulsification more challenging. 4 Prior studies have focused on the inflammatory profile of the aqueous after femtosecond laser pretreatment but not at the end of phacoemulsification, which is likely a better measure of the immediate postoperative inflammatory re- sponse. The effect of a low-energy femtosecond platform on these mea- sures had also not been investigated previously. In this study, Liu and colleagues compared aqueous cytokine and prostaglandin levels, oxidative stress, pupil size, and clinical flare between low-energy FLACS and conventional phacoemulsifica- tion. Aqueous profiles before laser pretreatment or at the beginning of surgery and after phacoemulsifica- tion were measured. The effect of preoperative non-steroidal anti-in- flammatory drug (NSAID) use on these parameters was also evaluated. Study summary A randomized controlled trial was designed to compare low-energy femtosecond laser-assisted cataract surgery (FLACS) to conventional phacoemulsification. The study took place at a Singaporean eye hospi- tal and consisted of 70 patients. Thirty-five patients with bilateral cataracts received conventional phacoemulsification in one eye and FLACS (FLACS group) using the LDV Z8 system (Ziemer Ophthal- mic Systems, Port, Switzerland) in the other eye 3–4 weeks later. An additional age-matched and cataract density-matched prospective cohort of 35 subjects received FLACS with preoperative NSAID administration (FLACS-N group, which received 0.4% topical ketorolac trometh- amine four times daily 24 hours prior to surgery). For the FLACS and FLACS-N groups, the femtosecond laser performed the corneal incision, anterior capsulotomy, and lens frag- mentation steps. With limbal paracentesis, aque- ous humor was collected after laser pretreatment for the FLACS and FLACS-N groups, before phacoemul- sification for the conventional phacoemulsification group, and after phacoemulsification for all groups. Levels of malondialdehyde (MDA, a free radical and measure of oxidative stress), prostaglandin E2 (PGE2), and 45 different cytokines were measured. Pupil size and clin- ical flare between the groups were compared. After laser pretreatment, FLACS had statistically significant higher levels of PGE2 and interleukin-1 receptor antagonist (IL-1RA) as com- pared to conventional phacoemul- sification. Preoperative NSAID use significantly decreased the level of PGE2 in FLACS to the same level as that in conventional phacoemulsifi- cation. FLACS caused intraoperative miosis, but the frequency of clinical- ly significant intraoperative miosis in FLACS was significantly reduced by preoperative NSAID use (20% vs. 46%). MDA levels and clinical flare were insignificantly higher in FLACS than conventional phacoemulsifi- cation. After phacoemulsification, PGE2 levels increased in all groups, and there was no significant difference among the groups. After phacoemul- sification, MDA levels also increased in all groups. The increase in MDA Background As ophthalmology residents at the University of California, Los An- geles (UCLA), we perform cataract surgery at four different hospitals. During our final year of residency, we spend 6 weeks in the cataract and refractive clinic at Stein Eye Institute, where we can offer our patients femtosecond laser-assisted cataract surgery (FLACS). Only a few other residencies in the country give residents the unique opportunity to perform FLACS. As cataract surgery continues to evolve, it has become increasingly important for oph- thalmologists in training to have access to the latest technologies, since these advancements have the potential to improve patient safety and outcomes. From a training perspective, residents must learn to critically evaluate the impact of new tech- nologies, as the adoption of tech- nologies like FLACS affects surgical outcomes and alters the cataract surgery learning curve. Prechopping the nucleus with a femtosecond la- ser has the advantage of minimizing phacoemulsification power, postop- erative corneal edema, and corneal endothelial trauma. 1 On the other hand, when compared to conven- A review of "Changes in aqueous oxidative low-energy femtosecond laser-assisted Kevin Miller, MD, chief of the cataract and refractive surgery division, David Geffen School of Medicine at UCLA Aqueous prostaglandin and cyto- kine levels provide insight into the severity and duration of low-grade surgical inflammation. I asked the UCLA residents to review this randomized study from the current issue of JCRS comparing FLACS and phaco and the efficacy of topical NSAIDs. —David F. Chang, MD, EyeWorld journal club editor UCLA residents, from left: Eric Shieh, MD, Patrick Lee, MD, and Christine Bokman, MD Source: UCLA

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