EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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This CME supplement is supported by unrestricted educational grants from Alcon and Bausch + Lomb. present when we enter the eye with the phaco tip. It is prudent to urge caution when discussions about the latest femtosecond lasers occur, as surgeons are using substantial volumes of I/A through the eye to achieve some of the low phaco times. Ideally, surgeons attempt to keep disruption of other tissue and heat damage to a minimum. See Table 1 for the currently approved devices and their respective indications. Personal experience with LACS I have been performing femtosec- ond LACS since 2010. Among the initial concerns was how these lasers would affect intraocular pressure or temperature, and whether they would increase the risk of macular edema. The literature predominant- ly favors LACS: LACS was found to cause less corneal swelling in the early postoperative period. 13 It was suggested LACS causes less trauma to corneal endothelial cells than stan- dard phacoemulsification 13 Effective phacoemulsification time is signi - cantly reduced with LACS. 14 Nagy et al. demonstrated re- duced incidence of macular edema on optical coherence tomography as compared to standard phacoemul- sification 15 Even more recently, Conrad-Hengerer et al. found LACS does not increase the risk of macular edema 16 and does not affect cortex removal times compared to standard phaco. 17 However, Schultz et al. found prostaglandins rise immediately after femtosecond treatment. 18 This suggests future patients may be better served if they are treated with NSAIDs to maintain mydri- asis before undergoing LACS. My personal preop/postop regimen for uncomplicated patients undergoing cataract surgery involves using a topical NSAID for 2 days preop and for 4 weeks postop. Topical steroids are also used for the same duration. Topical antibiotics are used for 1 week postop. In all LACS cases I still use some level of phaco to remove residual lens material. But any substantial reduction in phaco energy is highly beneficial for the patient and for reducing the risk of postop inflammation. References 1. Lundstrom M, Barry P, Henry Y, et al. Evi- dence-based guidelines for cataract surgery: guidelines based on data in the European Registry of Quality Outcomes for Cataract and Refractive Surgery database. J Cataract Refract Surg. 2012;38(6):1086–93. 2. Sorensen T, Chan CC, Bradley M, et al. Ul- trasound-induced corneal incision contracture survey in the United States and Canada. J Cataract Refract Surg. 2012;38(2):227–33. 3. DeBry P, Olson RJ, Crandall AS. Comparison of energy required for phaco-chop and divide and conquer phacoemulsific tion. J Cataract Refract Surg. 1998;24(5):689–92. 4. Fine IH, Packer M, Hoffman RS. Use of power modulations in phacoemulsific tion. Choo-choo chop and flip phacoemulsifi tion. J Cataract Refract Surg. 2001;27(2):188–97. 5. Koch PS, Katzen LE. Stop and chop phacoemulsific tion. J Cataract Refract Surg. 1994;20(5):566–70. 6. Wong T, Hingorani M, Lee V. Phacoemul- sific tion time and power requirements in phaco chop and divide and conquer nucle- ofractis techniques. J Cataract Refract Surg. 2000;26(9):1374–8. 7. Zetterstrom C, Laurell CG. Comparison of endothelial cell loss and phacoemulsific tion energy during endocapsular phacoemul- sific tion surgery. J Cataract Refract Surg. 1995;21(1):55–8. 8. Akahoshi T. Phaco prechop: Manual nucleofracture prior to phacoemulsific tion. Op Tech Cataract Ref Surg. 1998;1:69–91. 9. Elnaby EA, El Zawahry OM, Abdelrahman AM, Ibrahim HE. Phaco Prechop versus Divide and Conquer Phacoemulsific tion: A Prospec- tive Comparative Interventional Study. Middle East Afr J Ophthalmol. 2008;15(3):123–7. 10. Sippel KC, Pineda R, Jr. Phacoemulsific - tion and thermal wound injury. Semin Ophthalmol. 2002;17(3-4):102–9. 11. Devgan U. Surgical techniques in phacoemulsific tion. Curr Opin Ophthalmol. 2007;18(1):19–22. 12. Abell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsific tion time using fem- tosecond laser pretreatment. Ophthalmology. 2013;120(5):942–8. 13. Takacs AI, Kovacs I, Mihaltz K, et al. Central corneal volume and endothelial cell count following femtosecond laser-assisted refractive cataract surgery compared to conventional phacoemulsific tion. J Refract Surg. 2012;28(6):387–91. 14. Mayer WJ, Klaproth OK, Hengerer FH, Kohnen T. Impact of crystalline lens opacific - tion on effective phacoemulsific tion time in femtosecond laser-assisted cataract surgery. Am J Ophthalmol. 2014;157(2):426–32 e1. 15. Nagy ZZ, Ecsedy M, Kovacs I, et al. Macular morphology assessed by optical coherence tomography image segmentation after femtosecond laser-assisted and standard cataract surgery. J Cataract Refract Surg. 2012;38(6):941–6. 16. Conrad-Hengerer I, Hengerer FH, Al Juburi M, et al. Femtosecond laser-induced macular changes and anterior segment inflamm - tion in cataract surgery. J Refract Surg. 2014;30(4):222–6. 17. Conrad-Hengerer I, Schultz T, Jones JJ, et al. Cortex Removal After Laser Cataract Surgery and Standard Phacoemulsific tion: A Critical Analysis of 800 Consecutive Cases. J Refract Surg. 2014:1–5. 18. Schultz T, Joachim SC, Kuehn M, Dick HB. Changes in prostaglandin levels in patients undergoing femtosecond laser- assisted cataract surgery. J Refract Surg. 2013;29(11):742–7. Dr. Dell is the director of refractive and corneal surgery at Texan Eye and medical director of Dell Laser Consultants, Austin, Texas. Supported by an unrestricted educational grant from Bausch + Lomb Procedure Catalys Precision Laser Abbott Medical Optics Femto LDV Z6 Ziemer Ophthalmic Systems AG LENSAR LENSAR LenSx Alcon Victus Bausch + Lomb Anterior capsulotomy X X X X Lens fragmentation X X X X Corneal incisions X X X X X Arcuate incisions X X X X X Table 1. Femtosecond lasers for cataract surgery: U.S. approvals as of July 31, 2014