Eyeworld

EW MEETING REPORTER 84 September 2011 The nitty gritty of technique The third session of the day focused on criteria for patient selection, pre- op and post-op pharmaceutical regi- mens, the treatment of astigmatism, and the management of intraopera- tive complications and complicating factors. Dr. Talamo discussed some of the complications that concern sur- geons with regard to laser-assisted cataract surgery—failure to dock in cases with a tight orbit, ble- pharospasm, or conjunctivochalasis; globe tilt or decentration; corneal folds; suction loss; and residual bub- bles. He explained that in some of these instances, one may continue as planned, but in cases such as suc- tion loss during capsulotomy, in- complete capsulotomy, or residual bubbles, the laser treatment should be aborted and the surgeon should convert to manual treatment. Kasu Prasad Reddy, M.D., India, briefly discussed the benefits of intelligent pressure control (IPC) offered by the laser he uses and noted that he uses the phaco tip for capsulotomy only in instances where the capsulotomy is complete —if incomplete, he extracts the cap- sule manually. Dr. Donnenfeld concluded the session by offering up the following lessons learned: 1) use no ointments or gels—they preclude good suc- tion; 2) patients must be compli- ant; 3) good dilation is needed; 4) require moderate interpalpebral ex- posure; 5) redundant conjunctiva can prevent suction; and 6) pre-op non-steroidals are important—pupils will come down significantly if not used (ideally administered 3 days pre-op). Candidacy and astigmatism management: Open for debate In the final session of the day, D. Brian Kim, M.D., Dalton, Ga., along with Drs. Talamo, Reddy, Seibel, and Uy discussed astigmatic candidacy and management with Stephen S. Lane, M.D., Stillwater, Minn., acting as moderator. The panelists agreed that a pa- tient's pupils need to be centered and dilated to 6-6.5 mm or more in order to undergo astigmatic correc- tion with the femtosecond laser. Dr. Uy added that patients should have clear media, 7-mm central clear cornea, and a centered crystalline lens that is not subluxated. "You should be cautious if you have a subluxed lens," Dr. Uy said. Dr. Talamo addressed the con- cern that a cloudy or opaque corneal opacity would be cause for concern. But, "If you can see the iris detail through a corneal opacity, then the laser is going to treat just fine," he said. In a patient with compromised zonules, such as one who has pseu- doexfoliation, the procedure can be performed as long as there is no optic nerve damage, Dr. Talamo added. Dr. Seibel said that anything that will optically interfere with the imaging or laser, such as poor dila- tion, significant corneal scarring, or dense anterior cortical or opaque white cataracts, is a contraindication for the procedure. "Anything that will give us problems with docking, such as sur- face irregularity, conjunctival chala- sis, unusual orbital anatomy, and excess retropulsion" may also make a patient unsuitable for the femto procedure. An existing trabeculectomy bleb should be avoided as well because there is concern about bleb damage, Dr. Seibel said. Some manageable concerns in- clude anterior capsular fibrosis, den- sity of the lens nucleus, and lens colors, Dr. Uy said. "We're not fazed by dark brown cataracts," he said. In the "not so good candidates" category, Dr. Uy said, are patients with significant corneal opacities. Small ptyergia may result in suction loss. Dr. Uy said surgeons may pro- ceed with caution on black cataracts, maybe performing a capsulotomy and lens fragmentation, but that's it. "Be prepared to do some extra maneuvers if the orbital anatomy is not very favorable," he said. "In small palpebral fissures, sedation and local block can facilitate appli- cation of interface and docking." Dr. Lane said astigmatic correc- tion "has been an unmet need in cataract surgery, especially as pa- tients expect better refractive out- comes." He added, "Our ability to do that with cataract surgery has cer- tainly been lacking," he said. "The opportunity to do that better is what we're looking for." He cited a study by Warren Hill, M.D., which showed that 89% of patients have 0.25 D of astigma- tism. "The opportunities are great if the laser can deliver on astigmatic correction," he said. Dr. Kim agreed that demand is increasing. "When we're going to raise the price, we're going to raise the expectation," he said about astigmatic correction performed with the femtosecond platform. "Why do we pay attention to astig- matism? It's because it affects vision. Reporting live from the ASCRS/ EyeWorld Town Hall Meeting on Laser- Assisted Cataract Surgery, Chicago, July 14-17, 2011 Editors' note: This Meeting Reporter contains original reporting by the EyeWorld news team.

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