EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/194331
38 EW CATARACT October 2013 Complicated cataract cases How to perform femtosecond laser surgery for small pupil cases by William B. Trattler, MD F emtosecond laser-assisted cataract surgery is going mainstream very quickly. Its adoption will likely be much faster than that of phacoemulsification 30 years ago. I expect the majority of western surgeons to be performing most of their cases with this technology 10 years from now. Along the way, there will be hurdles and obstacles to overcome. The list includes patients with small lid fissures, deep set eyes, scarred corneas, post keratoplasty corneas, radial keratotomy incisions, kyphosis, and chronic obstructive pulmonary disease. Small pupils, posterior synechiae, and eccentric pupils are also on the list. In this issue of EyeWorld, William Trattler, MD, describes an approach to patients with small pupils that has been widely publicized by Burkhard Dick, MD, and William Culbertson, MD. It involves intraoperative placement of a Malyugin ring before the laser capsulorhexis and lens fragmentation steps. If a surgeon uses the laser for the incisional steps of surgery, there must necessarily be a double dock. It should be noted that the small pupil femtosecond laser approach works only if the patient interface does not raise the intraocular pressure very much. Otherwise, the incision will leak and suction will be lost. Kevin M. Miller, MD, Complicated cataract cases editor F emtosecond laser-assisted cataract surgery appears to be an impressive technology that has the ability to help improve visual outcomes and reduce complications. While ophthalmologists have honed their surgical skills and are qualified to perform cataract surgery without the femtosecond laser, it doesn't take long to realize that there are patients who may benefit from the use of the femtosecond laser. From patients with loose zonules to cases with dense cataracts, the ability of the femto laser to precisely perform a number of key steps in the cataract procedure has led to the growing understanding of how this technology may lower the risks associated with surgery. One of the big challenges is the use of femto laser technology in cases of small pupils. The femtosecond imaging system needs a clear line of sight of both the anterior and posterior capsules so that calculations can be performed to optimize lens fragmentation. When the pupil is small, it can be challenging for the imaging systems to determine the precise location of the posterior capsule. In my experience with the LENSAR laser (Orlando, Fla.), the laser can effectively image the lens with a pupil size as small as 4.5 mm, and can create a capsulorhexis as small as 4.0 mm. In cases with sub5.0 mm pupil size and relatively dense lenses, I have been quite im- Cross-sectional image of a patient with a dense cataract demonstrating that the LENSAR software can autodetect the front and back surface of the cornea and lens pressed with how the femtosecond laser performs. An additional challenge, however, is what to do on cases where the pupil size is exceptionally small. H. Burkhard Dick, MD, chairman, University Eye Hospital Bochum, Germany, and William W. Culbertson, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miami, have both shared that their preferred method for small pupil cases is to start under the surgical microscope and dilate the pupil with a Malyugin ring (MicroSurgical Technology, MST, Redmond, Wash.). The patients are then brought under the femto laser, where the surgeons can easily perform the femtosecond laser procedure due to the presence of a large pupil. Following this, the patient is placed back under the surgical microscope, where the rest of the procedure is performed. Another group of patients who can benefit from the femtosecond laser is patients with dense cataracts, or even white cataracts. The femtosecond laser works with the help of image guidance, either OCT or 3D-CSI. Imaging of the lens allows the laser to determine the precise location of the lens capsule, and in some cases, the geometric center of the lens capsule. The image-guidance feature allows the laser spots to be delivered precisely to the lens capsule, allowing for a circular capsulorhexis, even when visualization of the lens capsule through the surcontinued on page 39 A variety continued from page 35 pore National Eye Centre. "I would still choose the Victus, which is able to effectively treat almost all my patients," she said. But she also said a Catalys laser might help "to treat cases that require no phaco energy (which are not common) and eyes that are unable to tolerate elevation of intraocular pressure." Dr. Serafano said he would definitely order multiple femtosecond lasers if possible. In his two surgery centers, one has a LenSx laser and one does not. "My preference is to use the LenSx on all cataracts if possible," he said. Dr. Rivera said that if it was a possibility, he would have a Catalys laser in all four operating suites in the ambulatory surgery center he works in. Would you choose the femto laser for yourself? Many surgeons agree that they would want the femtosecond laser to be used if they were undergoing the cataract procedure. "Femtosecond laser cataract surgery is the way to go," Dr. Uy said. "That is what I would want for my cataract surgery, as well as for the surgery of my loved ones." "My answer to this question is a completely enthusiastic 'yes!'" Dr. Rivera said. Dr. Serafano said he has the same opinion today as he expressed at an ethics symposium at the 2012 ASCRS•ASOA Symposium & Congress. "If I needed cataract surgery, I would seek an ophthalmologist who uses a femtosecond laser—no doubt about it," he said. EW Editors' note: Dr. Uy has financial interests with LENSAR. Dr. Chee has financial interests with Bausch + Lomb/Technolas. Dr. Serafano has financial interests with Alcon. Dr. Rivera has no financial interests related to this article. Contact information Chee: chee.soon.phaik@snec.com.sg Rivera: rpriveramd@aol.com Serafano: serafano@verizon.net Uy: harveyuy@yahoo.com