EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/511377
EW NEWS & OPINION 16 May 2015 cortex fibrosis, and anterior capsule phimosis. I discontinued femto in July 2013, as it increased my capsule complication rate 16 times, and did not improve vision or refraction. "The hydrodissection wave was less effective against the femto-dis- rupted lens. I was surprised how often I needed to YAG the anterior capsule with femto cases. I saw aggressive anterior capsule phimosis that I have never seen before. "See our paper in Ophthalmology, Jan. 2014. 1 Our electron microscope images from the Catalys (Abbott Medical Optics, Abbott Park, Ill.), LenSx (Alcon, Fort Worth, Texas), and LENSAR (Orlando, Fla.) appear to show that all the brands cut the capsule in the same way, with a serrated capsule edge, and pits from aberrant misfiring. It is reasonable to conclude that all brands will have similar clinical problems. "We are independent of indus- try. We compared our consecutive manual and femto cataract cases. There were no clear lens extractions included. "It is easy to achieve a low complication rate by removing clear lenses. Many of the papers on femto are merely audits from practices with a high proportion of refractive patients. They are of little use to 'real cataract' practices. It will take an independent randomized controlled trial to lead me back into femto cataract surgery." Finally Sadeer Hannush, MD, gave this case extensive consider- ation: "Dr. Safran brings to light many keen observations regarding the mechanism of subluxation of a Crystalens IOL after FLACS, followed by appropriate surgical management of the pathology. I have observa- tions in 3 categories: 1) Management of a visually signif- icant subluxated IOL (of any type) in the absence of posterior capsular support, as well as the frequent absence of a stable anterior capsule. It behooves surgeons tackling this problem to be familiar with: a) A transscleral approach (pars pla- na or slightly anterior) to the an- terior vitreous cavity for removal of vitreous, residual lens material, and planning of fixation of the replacement posterior chamber IOL (PCIOL) b) A strategy for repositioning or replacement, partial or complete, of the subluxated IOL c) At least one go-to technique and lens of choice for scleral fixation of a PCIOL otherwise very thoughtful surgeon dismissed the advance, saying that it was the same as a can opener capsulotomy with the punctures very close together. Unfortunately that assessment, like the femto CCC being presumably as strong as a true CCC, violates the laws of physics, as a femto CCC is really a misnomer. It is not truly continuous. "This anecdotal trend in Z syndrome seems ominous, as fibrosis increases with time, and we are still very early into the timeline of wide- spread femto. We can expect to see more cases like this one." Stanley J. Berke, MD, added his thoughts on this case: "I agree that there IS a difference between femto versus manual rhexis—especially with an accommodating IOL—and that is demonstrated in the first slit lamp photo. The capsular bag has contracted in an irregular fash- ion, which has caused a severe Z syndrome. This seems to be more common with femto cases, while it is rare with manual cases. "In addition, when you noted 'no zonules inferiorly,' this was probably a result of the exaggerated and irregular capsular contraction associated with the femto laser. "In 10 years doing Crystalens with manual rhexis, I never had one case of Z syndrome. However, based on my experi- ence, and the experience of others doing FLACS, there seems to be an increased incidence of Z syndrome. I suggest that surgeons use caution with FLACS in patients receiving an accommodating IOL." Lisa Arbisser, MD, gave her thoughts: "This does need to be shown widely, as there are so many people planning cases with femto, thinking it will help them with their subluxated lens and planning to place hooks on the edge. I won- der how many have experienced tears, as I reserved the femto for true refractive cases with 1-piece IOLs and found it satisfactory. [This case is] not shocking considering the scanning electron microscopy images of the capsulotomy. How- ever, I fail to understand why there should be more fibrosis with femto cases, particularly in light of a 2012 paper that won Best Paper of Session at ASCRS by Buddy Culbertson, MD, showing less contraction of the capsule edge with femto versus manual. It was a good paper. Thanks for sharing." Peter E.J. Davies, MD, com- mented: "I am not surprised by this case. My experience is that femto results in increased cortex retention, Rhexis continued from page 14 Figure 3. The eye as it appears at the onset of the case. Dr. Safran is seated temporally. Figure 4. The lens optic has been removed and iris retractors are holding the anterior capsule in place. Further PPV is being carried out. Figure 5. A radial anterior capsule tear has begun despite the presence of an intact rim of anterior capsule. The tear begins UNDER the ring of fibrosis at the capsul edge. continued on page 18 rePlay online content