Eyeworld

Presented at the 2013 ASCRS• ASOA Symposium & Congress, Wiley et al. analyzed 50 consecutive surgeries (16 pupil, 34 scanned cap- sule) over a 2-month period. 4 The capsulorhexis position was guided by the laser software interpretation of the capsule bag center, based on the laser-obtained OCT images. The group showed complete IOL optic overlap was better with scanned capsule (100%) than with pupil centration (75%). There are more and more studies being discussed on the podium and in the literature that argue the femtosecond laser con- sistently provides better centration of the capsulotomy than manual techniques. What we have not yet shown categorically is whether the femtosecond laser will also help us improve our refractive outcomes. Those studies (understandably) take significantly longer to parse out over the long term. Limbal relaxing incisions Astigmatic correction can be achieved through toric lenses or through limbal relaxing incisions (LRIs). Measuring astigmatism con- sistently across patients and across visits (especially for those with lower levels of astigmatism) is sometimes challenging. Incisions may be a science, but the response remains unpredictable, due to patient age, corneal diameter/curvature, pa- chymetry, corneal biomechanics, or intraocular pressure. The femtosecond laser creates precise dissectible arcuate incisions that are consistently more uniform than what can be created manually with a diamond blade. Studies have shown that for astigmatism correc- tion, LACS is able to treat low levels of cylinder and is more precise in preop measurements and axis alignment. 5 Using femtosecond lasers allows surgeons to fully customize and adjust their arcuate incisions on A s ophthalmologists, we continually strive to give our patients the best pos- sible vision. Even when we're performing cataract surgery, we believe something could still make our outcomes better. Our goal is happy patients. Visual outcomes are crucial but irrelevant if the patient leaves our care un- happy. Some examples of this are a –3 D patient who is corrected to 20/15 postop but unhappy because he/she has to wear reading glasses, or the patient who was unaware a monofocal lens would not necessar- ily reduce the need for spectacles. As surgeons, we need to clearly define patients' visual goals and needs, and then we need to ensure we have the appropriate tools and modalities to achieve those goals. With today's modern cataract surgery, those tools include laser-assisted cataract surgery (LACS), improved technol- ogy IOLs, and tools for laser vision correction to handle any residual refractive surprises. Just as important is the ability to reproduce results— time and time again. Techniques that can provide consistently repro- ducible outcomes will inevitably prove beneficial to our practices and our bottom lines. Growing use of LACS There has been an increasing amount of interest in LACS, with evidence in the peer-review litera- ture as well. In 2005, there was only one published paper on the topic. By 2013, there were 88 papers pub- lished with hard data from original research. That research has shown LACS can help improve capsulor- hexis creation and therefore lens centration, arcuate incisions, and lens fragmentation. A poorly centered capsule can result in a malpositioned haptic and IOL decentration. 1,2 Figure 1 shows a 1-piece lens half in the bag, half in the sulcus; ultrasound biomicroscopy confirms the situation. Capsulorhexis centration is cru- cial to ensuring excellent outcomes. In my hands, I prefer capsular bag centration. Studies have confirmed laser-created capsulotomy is more consistent than manual. 3 by Mark H. Blecher, MD Laser-assisted cataract surgery: driving for perfection Figure 1. A poorly centered capsule can result in IOL decentration. Source: N. Fram, MD Three tipping points in refractive cataract surgery Mark H. Blecher, MD Dr. Blecher is co-director of the cataract service at Wills Eye Institute in Philadelphia and is in practice at Philadelphia Eye Associates. He can be contacted at mhbmd@comcast.net.

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