Eyeworld

Supported by an unrestricted educational grant from Abbott Medical Optics a case-by-case basis. 6 I personally prefer the Donnenfeld nomogram (available at www.lricalculator.com). Surgeons are left to determine what percentage of the nomogram they will use; the optical zone is fully adjustable as well. Julian Stevens, FRCOphth, has developed a nomo- gram for femtosecond laser intras- tromal astigmatic keratotomy that involves 20% above and below left untouched, with a 90-degree inci- sion. 7 I personally prefer intrastro- mal because these arcuate incisions are less invasive—I dislike opening the cornea. Intrastromal arcuate incisions offer numerous advantag- es: no penetration of the epithelium, fast visual recovery, no foreign body sensation, minimal wound healing response, fine control of astigmatism correction, and a minimized likeli- hood for infection. Lens fragmentation LACS lens fragmentation can, in some cases, allow surgeons to pro- ceed without any phaco, and reduc- es the amount of phaco necessary in most cases and increases the ability to use I/A alone. 8,9 Each of the fem- tosecond platforms can precleave and soften the lens. The amount of phaco energy used will depend upon the fragmentation pattern chosen. In conclusion, LACS provides improvements in overall levels of predictability and consistency that on aggregate will improve outcomes. Studies have shown—and are con- tinually showing—LACS is beneficial for small amounts of astigmatism by providing greater precision and accuracy than manual procedures. LACS provides superb predictability in the capsulorhexis and with IOL centration, and provides ease of nu- cleus removal with less energy, less inflammation, and increased safety. References 1. Berdahl J, Goldberg D, Goldman DA, Shivaram A. Vaulted Anteriorly Captured Haptic. Cataract & Refractive Surgery Today. Bryn Mawr, PA: BMC Publications, 2013. 2. Agarwal A, Kumar DA. Ultrasound biomicros- copy used to report characteristics of transs- cleral-fixated glued IOLs. Ocular Surgery News. Thorofare, N.J.: Slack Inc., 2013. 3. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011;37(7):1189–98. 4. Wiley WF, Bafna S, Jones JJ. Optical coherence topography-guided capsule bag-centered fem- tosecond laser capsule. Presented at: American Society of Cataract & Refractive Surgery. San Francisco, CA: 2013. 5. Tamayo G. Clinical impact of managing astigmatism: Femtosecond arcuates vs. manual incisions. Presented at: American Society of Cataract & Refractive Surgery. Boston, MA: 2014. 6. Donnenfeld ED. Current and future opportu- nities for femtosecond laser cataract surgery to deliver a new generation of outcomes. Presented at: American Society of Cataract & Refractive Surgery. Boston, MA: 2014. 7. Stevens JD, Day AC, Lau NM. Nomogram for femtosecond nonpenetrating instrastromal astigmatic keratotomy during femtosecond laser-assisted cataract surgery. American Society of Cataract & Refractive Surgery. San Diego, CA: 2015. 8. Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laser-assisted cataract surgery with integrated optical coherence tomography. Sci Transl Med. 2010;2(58):58ra85. 9. Edwards KH, Frey RW, Naranjo-Tackman R, et al. Clinical outcomes following laser cataract surgery. Invest Ophthalmol Vis Sci. 2010;51 (E-abstract 5394). Discussion Dr. Lindstrom: To begin the discussion, if you're going to have a resident do a case, does the femtosecond laser make it easier? Dr. Blecher: At Wills Eye Hospital, we're fortunate enough to allow all our res- idents to do their cases with a femtosecond. The company we use has agreed to provide free interfaces so all of our residents can be certified in the laser. We have begun training and certifying all of our third-year residents in the use of the femto. One of our residents presented at the European Society of Cataract & Refractive Surgeons meeting that their outcomes with femto and non-femto across the entire year were no different. At Wills, each resident performs close to 200 cataract surgeries, and maybe 10 of those will be with the femto laser. But it was interesting to learn there was no negative aspect, and from what I've seen, it will be incorporated fairly easily into their armamentarium. Dr. Lindstrom: Dr. Dell, when you do femto, is it because surgical aspects are easier or because you're hoping some aspect is better? Steven J. Dell, MD: It took us a long time with the IntraLase to drill down deep enough to tease out the clinical benefit over mechanical microkeratomes, and during that time, the lasers were getting better. For me, the primary benefit of femto for cataract surgery is capsulotomy. I don't have difficulty fragmenting the lens, and my diamond corneal incisions rival or surpass what I get with femto. Dr. Lindstrom: Dr. Blecher, what about anterior capsule rim tears? That's the nightmare for everyone. Is this a myth, or is it real? Dr. Blecher: We're still sorting all that out, I think. Some of the papers that discussed that were using first-generation lasers, and some of the results were very laser-specific. Those same authors upgraded their lasers and the numbers that report larger capsular tear percentages dropped by 95%. At Wills we have not seen a single capsular tear in our entire institution. I do not believe it's an issue if you're using current technology and you're well trained. Can you get it? Theoretically, of course. Nothing is perfect. Dr. Dell: I agree. I think it is somewhat platform-specific, but I've been satisfied with the capsulotomy. Dr. Lindstrom: I haven't had an anterior capsule rim tear in a femto case either, but it is something to be cognizant about as it does concern some people. I like the way arcuate incisions with the femtosecond look versus what I can do with a diamond, but I'm not yet convinced they result in better outcomes. With the future toric multifocal lenses, what do you think will be the indication for corneal relaxing incisions? Dr. Dell: On the low end of astigmatism it becomes more difficult to precisely find the axis of the astigmatism. If you're off-axis with, say, 3.25 D of astigma- tism, you could argue that a big arcuate incision, which is going to flatten a large number of degrees of cornea, may actually be better. Without a precisely aligned toric, you're not going to get the desired results for your patients. I don't think arcuate incisions are going to go away, but we all recognize the accuracy and superiority of torics once you get over around 1 or 1.5 D. John A. Vukich, MD: We used to think steel blades were good until we had diamond blades. Now we think lasers may be best, but I think inherently the biomechanical predictability of the cornea is going to be the limiting factor, and it will always be the rate-limiting factor. Toric lenses are clearly the way to go for higher levels of astigmatism, but femtosecond lasers will likely find a niche for lower levels. Dr. Lindstrom: I can see myself going on to on-axis incisions and toric IOLs, but I see corneal relaxing incision use declining rapidly.

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