JAN 2014

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

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January 2014 vacuum application, the mean (± standard deviation) IOP rise was 11±3 mm Hg, and persistent elevation above baseline was maintained for two minutes after laser capsulotomy and lens fragmentation were completed. This was found to be the case independent of central corneal thickness (CCT), vacuum time, docking attempts, and treatment time. Intraocular pressure related complications on the retinal vasculature or optic nerve head must be considered. Cilioretinal artery occlusion and anterior ischemic optic neuropathy are concerning.4 Selecting outcome measures to best assess this new procedure must also go beyond complication rates. The argument for FLACS begs the question: Does more precise capsulorhexis centration and size translate into improved visual outcomes and patient satisfaction? During an undilated slit lamp exam the intraocular lens edge and capsulorhexis are rarely visible and the visual significance of a predictable capsulorhexislens overlap is debatable. Several studies have suggested that a predictable capsulorhexis affords better control of postoperative intraocular placement within the capsular bag. 5-8 This has to be weighed against the possibility, now shown in several studies including a recent study by Abell et al, that femtosecond-assisted capsulorhexis appears to be less resilient to tears and radialization than the current gold standard of continuous tear circular capsulorhexis.9 While the prospect of new technology to simplify the steps of cataract surgery is certainly appealing, the potential benefits of adopting this new technology must be weighed against the potential complications. Considerations should include the increased cost of purchasing and maintaining the laser, the apparent increased risk of radialization of the capsulorhexis, as well as the loss of surgical skill by surgeons in training and early adopters. Potential benefits include improved refractive outcomes, better reproducibility of capsulorhexis and incision size, shape and configura- Complications of femtosecond laser-assisted cataract surgery Zoltan Z. Nagy, MD, DSc, Agnes I. Takacs, MD, Tamas Filkorn, MD, Kinga Kránitz, MD, Andrea Gyenes, MD, Éva Juhász, MD, Gábor L. Sándor, MD, Illes Kovacs, MD, PhD, Tibor Juhász, MD, PhD, Stephen Slade, MD J Cataract Refract Surg (Jan.) 2014; 40:20–28 Purpose: To analyze complications of femtosecond lasers used for cataract surgery. Setting: Department of Ophthalmology Semmelweis University, Budapest, Hungary. Design: Retrospective analysis. Methods: Intraoperative complications of the first femtosecond laser-assisted (Alcon LenSx) cataract surgeries were collected. Possible complications of femtosecond capsulotomies and their management were also assessed. Results: The 100 complications were as follows: suction break (2%), conjunctival redness or hemorrhage (34%), capsule tags and bridges (20%), anterior tear (4%), miosis (32%), and endothelial damage due to cut within the endothelial layer (3%). There were no cases of capsule blockage or posterior capsule tear. During the learning curve, there was no complication that would require vitrectomy. All complications occurred during the first 100 cases. Conclusions: Femtosecond laser cataract surgery had a learning curve during the first 100 cases. With cautious surgical technique, the complications can be avoided. The femtosecond laser-assisted method was efficient and safe for cataract surgery. Financial disclosure: Drs. Nagy, Juhász, and Slade are consultants to Alcon. No other author has a financial or proprietary interest in any material or method mentioned. EW RESIDENTS 55 Mayo Clinic Department of Ophthalmology residents. Back row, left to right: Drs. Elizabeth A. Atchison, Rachel C. Mercer, Francisco Castillo, Maya H. Maloney, and Harish Raja. Front row, left to right: Drs. Victoria Lossen, Jasmina Bajric, Heidrun E. Gollogly, Saranya C. Balasubramaniam, and Saba T. Alniemi. Missing: Drs. Sejal R. Amin and Aarika L. Menees tion, as well as the possibility to fashion the incisions or nuclear segments in essentially any shape imaginable. The latter may ultimately evolve into novel surgical techniques and potentially better patient outcomes. As was recently analyzed by Abell et al, in an age where healthcare expenditure are under scrutiny, the added cost of FLACS is not justified by the gains in patient outcomes and, in fact, the out-of-pocket expenses may decrease patient satisfaction.10 In the January issue of JCRS, the articles by Chang et al and Nagy et al help shed light on how incorporating femtosecond laser into cataract surgery affects both surgeon experience and patient safety. As this new technology finds a role in patient care, their experiences may help guide readers of this journal. EW References 1. Bali SJ, Hodge C, lawless M, Roberts TV, Sutton G. Early experience with the femtosecond laser for cataract surgery. Ophthalmology. 2012 May; 119(5):891-9. 2. Roberts TV, Lawless M, Bali SJ, Hodge C, Sutton G. Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases. Ophthalmology. 2013;120(2):227-33.3. Jones D, Karp Cl, Heigle TJ (1999). Principles and techniques of cataract surgery phacoemulsification: Methodology and complications. Ophthalmic Surgery: Principles and Techniques (283-312). Malden, MA. Blackwell Science. 3. Menikoff JA. A case-control study of risk factors for postoperative endophthalmitis. Ophthalmology. 1991;98-1761-1768. 4. Maden A, Yilmaz S, Yurdakul NS. Nonarteritic ischemic optic neuropathy after LASIK with femtosecond laser flap creation. J Neuroophthalmol. 2008;28(3):242-3. 5. Ravalico G, Tognetto D, Palomba M, et al. Capsulorrhexis size and posterior capsule opacification. J Cataract Refract Surg. 1995;22:98-103. 6. Sanders DR, Higginbotham RW, Opatowsky IE, Confino J. Hyperopic shift in refraction associated with implantation of the single-piece Collamer intraocular lens. J Cataract Refract Surg. 2006;32:2110-2. 7. Walkow T, Anders N, Pham DT, Wollensak J. Causes of severe decentration and subluxation of intraocular lenses. Graefe's Arch Clin Exp Ophthalmol. 1997;236:9-12. 8. Trikha S, Turnbull AM, Morris RJ, et al. The journey to femtosecond laser-assisted cataract surgery: new beginnings or a false dawn? Eye. 2013;27:461-73. 9. Abell RG, Davies PE, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior Capsulotomy Integrity after Femtosecond Laser-Assisted Cataract Surgery. Ophthalmology. 2013 Sep 28. pii: S0161-6420(13)00731-8. doi:10.1016/j.ophtha.2013.08.013. [Epub ahead of print]. 10. Abell RG, Vote BJ. Cost effectiveness of femtosecond laser-assisted cataract surgery versus phacoemulsification cataract surgery. Ophthalmology 2013 Oct 10. pii: S01616420(13)00696-9. doi: 10.1 016/j.ophtha.2013.07.056. [Epub ahead of print]. Contact information Khanna: Khanna.Cheryl@mayo.edu

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