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Next-generation lens extraction: Customizing phacoemulsification in LACS by Tal Raviv, MD Laser fragmentation options and dual pumps provide flexibility for each case R esearch has demonstrated that lens fragmentation with the femtosecond laser provides measurable benefits in reduced phacoemulsification time, endothelial cell loss, and postoperative inflammation. 1–3 With the Catalys Precision Laser System (Abbott Medical Optics, Abbott Park, Ill.) in addition to creating corneal incisions and capsulotomy, we can segment and soften the cataractous nu- cleus. The segmentation option enables 5 surgeons to split the lens into large quadrants or sextants, and fragmentation patterns allow surgeons to soften the lens to almost a slurry by adjusting the grid spacing. Relying on these features, we can customize phacoemulsification for each lens. Dr. Raviv is clinical associate professor of ophthalmology at Icahn School of Medicine at Mount Sinai, New York, and is founder and medical director of the Eye Center of New York. Figure 1. Pump advantages in laser-treated eye surgery. On examination, she had mod- erate dry eye with approximately 1.0 D against-the-rule residual astigmatism in her dominant eye and a spherical equiva- lent of near plano. To minimize further impact on her dry eye, we wanted to consider options other than an excimer enhancement. Af- ter ocular surface optimization, we elected to use the Catalys to perform astigmatic incisions. In this case, we programmed a paired astigmatic keratotomy of 80% with an ex- panded optical zone of 10.5 mm to keep the astigmatic incisions outside of the flap and inside the limbus. Our normal optical zone is set for 9.0 mm. Afterward, we simply opened the astigmatic inci- sions at the slit lamp. Her preoperative tomography demonstrated 1.0 D of against-the-rule astigmatism. After her femtosecond laser-assisted astigmatic keratotomy (FLAAK), her tomographic astigmatism was reduced to 0.2 D, with a refractive result of plano and resolution of her symptoms. Qualitative analysis here is important. Historically with manual astigmatic incisional surgery, I would observe decreased tomographic astigma- tism, but not typically full tomographic resolution. I observe this much more fre- quently with femtosecond laser astigmat- ic incisions, and I believe this is why we are seeing improvement in our refractive outcomes (Figure 2). Conclusion Astigmatic keratotomy is a key benefit of femtosecond lasers. We expect technolog- ic advances, including new nomograms that ideally will be validated. In the near future, we will have integrated guidance devices to guide our laser-created inci- sions. Femtosecond astigmatic LRIs allow surgeons to expand the range of can- didates for upper and lower limits of astigmatic correction and, as a result, candidates for multifocal IOLs. We feel that femtosecond-enabled astigmatic incisions are a key factor in the improved refractive outcomes we are observing with femtosecond laser IOL surgery. The future is bright, and I am excited to see just how good our outcomes will be with further advances such as intraoperative guidance for femtosecond laser astigmatic incisions. Reference 1. Villegas EA, Alcón E, Artal P. Minimum amount of astigmatism that should be corrected. J Cataract Refract Surg. 2014; 40:13–19. continued from page 4 continued on page 6

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