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EW CATARACT 46 September 2015 Since the lens is already fragment- ed, I rarely need to utilize a second intraocular instrument for lens ma- nipulation. The improved fluidics of the Centurion Vision System (Alcon, Fort Worth, Texas) result in a more efficient procedure with less cumu- lative dissipated energy (CDE) and less fluid moved through the eye, typically around 20 cc instead of the 50–100 cc we saw before. Since we are not putting instruments in and by Lauren Lipuma EyeWorld Staff Writer Three surgeons share how their technique has changed since incorporating the laser into practice W hether for correcting astigmatism, remov- ing the nucleus, or optimizing surgical efficiency, surgeons have to adopt a slightly different technique for femtosecond laser- assisted cataract surgery than for manual phaco. Most surgeons agree that there is a learning curve for the first 100 or so cases, and for phy- sicians just starting out with this procedure, it can be helpful to know what unexpected issues may come up during surgery. EyeWorld asked laser cataract surgery pioneers Robert J. Cionni, MD, medical director, The Eye Institute of Utah, Salt Lake City; Zoltan Nagy, MD, clinical profes- sor of ophthalmology, Semmelweis University, Budapest, Hungary; and Jonathan Talamo, MD, director, Massachusetts Eye and Ear Infirma- ry Waltham, Waltham, Mass., how their technique has changed since incorporating the laser into prac- tice. Here, in their own words, Drs. Cionni, Nagy, and Talamo describe what makes laser cataract surgery different from manual. How has the femtosecond laser changed your cataract surgical technique? "Since the lens is already fragmented, I rarely need to utilize a second intraocular instrument for lens manipulation." –Robert J. Cionni, MD "During hydrodissection, the lens should be moved up and down and must be rotated. This is the so-called 'rock and roll' technique. With this method, I never had any rupture of the posterior capsule." –Zoltan Nagy, MD "What I'll typically do is I'll start my day by treating 2 patients. One will immediately go into surgery and the other will wait and go in when the first one's done. So the delay is no more than 20 minutes." –Jonathan Talamo, MD Because you already have a cut in the anterior capsule, you have to be very careful not to destabilize the chamber when you enter the eye. In the unlikely event you have a resid- ual attachment between the capsular disc and the peripheral capsule, if you put uncontrolled tension on that area, you could have a tear in the capsule. So I'll enter very care- fully and inflate with viscoelastic to minimize any chamber instability. Then I'll proceed with what's called a dimple-down maneuver, where I'll use a cystotome, or more typically out of the side port incision, this incision seals much more easily as well. The corneal arcuate incisions are much more precise with a more predictable effect than any manual incision I've ever made. I prefer to limit cylinder reduction with arcuate incisions to 2 D or less, using a toric IOL for more significant astigmatism management. The surgeon must have a plan before entering the OR. Therefore, I see every patient in the morning before surgery and I decide what to do. Laser pretreatment is very short, so the surgeon should check all steps before starting the laser pedal. The second most important thing to do for those who start with this technology is to follow the contour of the capsulotomy to avoid anterior tears. The next important step is the gentle hydrodissection to allow the intralenticular gas bubble to leave the eye through the anterior cham- ber without causing rupture of the posterior capsule. During hydrodissection, the lens should be moved up and down and must be rotated. This is the so-called "rock and roll" technique. With this method, I never had any rupture of the posterior capsule. A special chopper is needed to fragment the crystalline lens, and from then on, the procedure is similar to manual phacoemulsification. During laser cataract surgery, a larger epinucleus may stay, which has a protective role for the posterior capsule. During irri- gation/aspiration (I/A), the surgeon should control this. Are you a fan of EyeWorld? Like us on Facebook at facebook.com/EyeWorldMagazine Find us on social media EyeWorld@EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews

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