Eyeworld

74 by Maxine Lipner EyeWorld Senior Contributing Writer All eyes on the laser T he femtosecond laser is making inroads into cataract surgery and has garnered a reputation for safety. Still, that does not mean practitioners will not face complications with the femtosecond approach. EyeWorld asked practi- tioners to talk about some of the issues they have come up against with femtosecond cataract surgery. Alice T. Epitropoulos, MD, clinical assistant professor, The Ohio State University Wexner Medical Center, Columbus, Ohio, has been doing femtosecond cataract surgery for the last year. "This technology provides surgeons with an exciting new op- tion to potentially improve patient outcomes and safety. Femtosecond laser-assisted cataract surgery may provide benefits, especially in cer- tain patients with denser cataracts or low endothelial counts. It also increases our chances of achieving emmetropia through more accu- rate astigmatic correction," said Dr. Epitropoulos. "But the technology brings with it a host of new financial and clinical challenges. As with any new technology, there is a learning curve associated with femtosecond cataract surgery, and complications may occur." Winning at tag removal One issue is that an incomplete capsulotomy can occur, Dr. Epitropoulos said. "Fortunately, with recent upgrades in software and patient interfaces, the incidence has decreased," she said, adding that incomplete capsulotomy used to happen in 10% of femto cases and is now less than 1%. Still, keeping this in mind, Dr. Epitropoulos urges practitioners to be vigilant when removing the cap- sular remnant because an unrealized adhesion can cause an anterior tear in the capsule with the potential to extend posteriorly. Some patients are at a slightly higher risk of developing a capsular tag or an incomplete capsuloto- my, she said. Any scarring, edema, or folds in the endothelium can reduce the quality of the image and contribute to capsular tags, she said. "Other factors might be patients who have a significant lens tilt or steep corneas such as keratoconus," Dr. Epitropoulos said, adding that in such cases, folds may be induced on the cornea with applanation. Neda Shamie, MD, associate professor of ophthalmology, Uni- versity of Southern California Eye Institute, Los Angeles, came across a case involving tags in one of her early attempts with the femtosecond laser. This was before improvements in the software, she said, and was a rare case that led to radialization. Tags can become an issue if they are unrecognized and the lens is under pressure, she explained. If the prac- titioner decompresses the anterior chamber, the tag can turn into a radial tear. "However, if it is recognized by the surgeon and handled in such a way where the tag is carefully broken without allowing it to radi- alize, it becomes a moot point," Dr. Shamie said. "I think the key point is to recognize where there may be a tag and when there is, address it as though it's an unfinished capsu- lotomy." This means reverting to traditional techniques of creating a circumlinear capsulotomy using Utrata forceps and tearing through the tag, Dr. Shamie said. To avoid this, particularly in initial cases, carefully move through the steps of going around the capsu- lotomy and make sure that there is no tag left, she instructed. Relieving bubble trouble If there are air bubbles behind the lens, Dr. Shamie recommended tog- gling the lens one way and then the other to allow these to egress out of the capsular bag before hydrodissect- ing. Dr. Epitropoulos agreed that the air bubbles generated from the laser should be gently decompressed. "Rapid and aggressive hydrodis- section can lead to posterior capsular rupture," Dr. Epitropoulos said. Prior to hydrodissection, Dr. Epitropoulos uses an Akahoshi Prechopper (Asico, EW SECONDARY FEATURE Finessing femtosecond cataract complications Westmont, Ill.) to complete the frag- mentation performed by the laser. This device allows the air bubbles to exit between the fragments. "I insert the prechopper where the laser has already cracked the nucleus and gently open the prechopper up and those bubbles automatically come through the nucleus frag- ments." This is followed by gentle hydrodissection. Likewise, Dr. Shamie said that hydrodissection can't be done the same way as in traditional cataract surgery. "It needs to be a gentle injection of fluid," she said. "The wave that we expect in our traditional cases should not be expected in these cases and should not be the goal in the hydrodissection." Instead, practitioners should aim for gentle spurts of balanced salt solution (BSS, Alcon, Fort Worth, Texas) around the capsulotomy to essentially break any adhesions between the capsule and the lens, but not necessarily to expect or want a fluid wave across the posterior lens, she said. February 2015 To allow air bubbles generated from the laser to egress, some practitioners use a prechopper to complete the laser fragmentation. Source: Alice T. Epitropoulos, MD " As with any new technology, there is a learning curve associated with femtosecond cataract surgery, and complications may occur. " –Alice T. Epitropoulos, MD

• Cover