Eyeworld

26 | EYEWORLD | NOVEMBER 2019 ATARACT C DEVICE FOCUS Contact information Devgan: devgan@gmail.com Patterson: larryp@ecotn.com by Rich Daly EyeWorld Contributing Writer He also found femtosecond laser-created capsulotomies did not always end up exactly where he thought they would. "I can do a manual capsulotomy and I can put it exactly where I want it to be," Dr. Patter- son said. The additional cost and time added to the procedure were cited by the doctors as a disadvantage for using femtosecond lasers to create capsulotomies. But among newer devices that cost less than femtosecond laser systems is the Zepto capsulotomy system. Zepto uses a handpiece attached to a laptop-sized console to create a "phase transition" of water molecules trapped between the device and the capsule to create capsulotomies. Dr. Patterson said one advantage of this device is that it is performed on the operating table, which keeps operating time short. In addition, some reports indicate that it results in a stronger capsule edge. "There may be some other advantages, but for right now those all cost extra money and you can't bill for the extra cost, so for the near future, we'll be sticking with manual capsuloto- mies," Dr. Patterson said. Creating the ideal capsulotomy For all planar, fixed-position IOLs, Dr. Devgan aims for a capsulorhexis that overlaps the edge of the optic 360 degrees while not covering a significant part of the optic. That means for the common IOL optic size of 6 mm, his ideal capsulorhexis is about 5–5.5 mm in diameter. "When we center this on the patient's visual axis, we will be able to hold the IOL optic securely, thereby giving better predictability in the effective lens position used for IOL calcu- lations, and better long-term stability and visual performance," Dr. Devgan said. His approach applies to monofocal, mul- tifocal, trifocal, extended depth of focus, and toric IOLs. Dr. Patterson strives for a capsulorhexis of 5.5 mm for the common 6-mm lens. S pecific patient situations and evolving views on technology are informing surgeons' approaches to capsuloto- my creation, a procedure that can be performed manually or with various devices. Manual, femto, and Zepto Uday Devgan, MD, performs manual capsulor- hexis, Zepto (Mynosys Cellular Devices) capsu- lotomies, and femtosecond laser capsulotomies, with his approach depending on the type of patient and their anatomy. "A routine case may not benefit from a Zepto or femto-laser capsulotomy as much as an intumescent, white cataract case," Dr. Dev- gan explained. "Even then, there is no guaran- tee of success and you can have an incomplete laser-made capsulorhexis in some cases." Surgeon skill is more influential on high-quality clinical outcomes, than use of technology like a femtosecond laser, Dr. Dev- gan said. For example, forceps can be used to create a 5-mm capsulorhexis, even if the pupil only dilates to 4 mm by passing the forceps tips under the iris—an approach is not possible with a femtosecond laser. In contrast, novice surgeons or those who have difficulty making an excellent capsulorhex- is may improve their results by using a femto- second laser or Zepto device, Dr. Devgan said. Larry Patterson, MD, performed femtosec- ond capsulotomies for 4 years and then about 2.5 years ago switched back to creating a manual capsulorhexis. Despite the expectation that fem- to-laser capsulotomies would increase accuracy and precision, Dr. Patterson found they weren't as strong as those created manually. His return to manual was reinforced by studies repeatedly finding femtosecond-created capsulotomies were more likely to tear under pressure. "It wasn't just the studies showing that, we were obviously getting more anterior capsular tears with the laser. I rarely have an anterior capsular tear now that we've switched back to 100% manual," Dr. Patterson said. Capsulotomy creation: Searching for perfection About the doctors Uday Devgan, MD Private Practice, Devgan Eye Surgery Clinical professor of ophthalmology Jules Stein Eye Institute Chief of ophthalmology, Olive View UCLA Medical Center Los Angeles Larry Patterson, MD Medical director Eye Centers of Tennessee Crossville, Tennessee Relevant financial interests Devgan: CataractCoach.com, Mynosys Patterson: None continued on page 28

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