Eyeworld

"But in clinical practice, I've started to be more critical of my manual capsulorhexis." Any part of the surgery that can help keep the IOL centered and pla- nar "will keep results similar, mak- ing it easier to evaluate your own nomogram and make adjustments to the nomogram as necessary," Dr. Trattler said. Additionally, lens fragmentation and cataract removal can be done atraumatically, he said, "so there's less risk of any zonular injury or dehiscence that could lead to some slight decentration of the lens- capsular bag complex." Using the femto to create the entry wound may also have benefits, Dr. Schallhorn said. "A trilaminar wound is less likely to leak, and theoretically we'll have more predictable surgically induced astigmatism," he said. In the foreseeable future, Dr. Trattler expects 3D analysis of the entire anterior chamber including the capsular bag and zonular configuration, which will make it easier to predict the final effective lens position for IOLs. Clinical experience Dr. Kontos' group is studying using the femto for cataract to correct lower levels of astigmatism, and "our preliminary numbers look re- ally good. We're making an impact on that group," he said, and most patients report not needing specta- cles postoperatively. The femto is already having a positive effect with complex cases, Dr. Yoo said. "Using the laser in pseudoexfoliation or weakened zonules with a very dense lens makes the case a little easier to manage," she said. Dr. Trattler said fragmenting dense cataracts is much easier with the femto, too, and reduces the total amount of phaco energy, resulting in less corneal edema postop. Dr. Kontos prefers the laser to marking the cornea in cases of astigmatism. "When the laser makes the mark, we can line up exactly on that and it's easy to verify we're on the right spot, whereas there's a bit more difficulty with manual mark- ing. Whether or not our femto marks are correct is another story," he said. Some surgeons are opting to use the laser regardless of payment "be- cause of the patient dynamics," Dr. Kontos said. "We're doing it because it makes more sense clinically. It's more likely to produce a good outcome in complex cases." Next to improve? With the consistent capsulorhexis, "I think it will lead to different IOL designs," Dr. Schallhorn said. "I pre- dict we'll see IOLs that are designed around the rhexis—we will know how the capsule will behave in any patient and that will allow us to design an IOL that takes advantage of that knowledge." Dr. Kontos said the field is al- ready evolving in terms of instru- mentation that takes advantage of the femto's qualities. "IOL develop- ment is a longer process," he said. "The capsulotomy is going to be the key for all future IOL designs, and it's because of the femto," Dr. Trattler said. "That 'sweet spot' we sometimes struggle to find isn't as much of an issue with the femto." Dr. Yoo said that some of the newer IOL designs (such as the bag-in-lens IOL developed by Marie-José Tassignon, MD) can already take advantage of the precise anterior capsulotomy. Patients will also drive the inno- vation, Dr. Kontos said. "With the laser, we're now able to tighten our refractive results down to where cataract is almost as good as our LASIK outcomes. We're finding we don't have to fine-tune as often as we used to, and that will end up driving referrals." EW Editors' note: Drs. Kontos and Schallhorn have financial interests with Abbott Medical Optics (Santa Ana, Calif.). Dr. Trattler has financial interests with Abbott Medical Optics, LENSAR (Orlando, Fla.), Alcon (Fort Worth, Texas), and Bausch + Lomb (Bridgewater, N.J.). Dr. Yoo has finan- cial interests with Abbott Medical Optics, Alcon, and Bausch + Lomb. Contact information Kontos: mark.kontos@empireeye.com Schallhorn: scschallhorn@yahoo.com Trattler: wtrattler@gmail.com Yoo: syoo@med.miami.edu June 2014 32-41 Feature_EW June 2014-DL_Layout 1 6/5/14 12:13 PM Page 35

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