Eyeworld

EW CATARACT 32 November 2015 struments to create perfectly round, consistent, central capsulotomies," he said. "IOLs are being developed to take advantage of this, which may give better centration and effective lens position predictability." EW Editors' note: Dr. Packard has financial interests with Alcon (Fort Worth, Texas), CAPSULaser, and Shire (Lexington, Mass.). Contact information Packard: eyequack@vossnet.co.uk by Ellen Stodola EyeWorld Staff Writer corneas in all patients, endothelial count as expected, well-centered and non-contracted capsulotomies, and no change in IOL position. "As surgeons, we should soon have a range of options available to make our capsulotomies more circular, predictably sized, and posi- tioned," he said. IOL manufacturers are beginning to create designs to take advantage of this. The capsulotomy has changed with cataract surgery, Dr. Packard said. "Now, we have many devices from lasers to metallic thermal in- techniques requiring the nucleus to be tilted would become much more difficult; and new phaco techniques were developed to overcome these difficulties. There was then the question of making the CCC more precise, he said. Size and centration become im- portant in the capsulotomy because both are needed when using multi- focal and toric IOLs and for effective lens position. Dr. Packard highlighted the introduction of the femtosecond laser and how it played a role in the evolution of the capsulotomy. The laser was first used by Zoltan Nagy, MD, in cataract surgery in 2008, and with the femtosecond laser, capsulo- tomies are truly circular and lack the variability seen in manual tech- niques, Dr. Packard said. However, as with any new technology, there are some caveats. Surgeons may need to use a second room to complete these procedures, and this in turn could interfere with the surgical flow. Ad- ditionally, the cost of the device and the cost of using it are both high, and true advantages needed to be proven. Now, Dr. Packard said, there is another laser approach: the thermal laser. He delved into results with the CAPSULaser (Los Gatos, Calif.) and mentioned the ZEPTO (Mynosys, Fremont, Calif.) and ApertureRx (Mount Pleasant, S.C.) lasers. The CAPSULaser is a thermal laser. By staining the anterior cap- sule with trypan blue, a selective target for the laser is created. The laser is not pulsed, Dr. Packard said, but it's continuous and is scanned in a single circular pattern to create the continuous curvilinear capsulot- omy. In the region of irradiation, the laser energy facilitates the molec- ular phase change of the capsular collagen IV to elastic amorphous collagen. As the collagen undergoes this phase change, it creates the cap- sulotomy with a rim that has a high degree of elasticity and tear strength associated with the amorphous collagen. Preliminary clinical results with the CAPSULaser have shown no pupil constriction after laser use and no untoward anterior chamber activity postoperatively. Currently there are 10 patients with 2-month follow-up data, and there are clear D uring the 2015 European Society of Cataract & Refractive Surgeons (ESCRS) meeting, the Binkhorst Lecture was presented by Richard Packard, MD, Windsor, U.K., on "The evolution of the capsulotomy: from crude forceps to precision laser." Dr. Packard is a longtime ESCRS board and commit- tee member and is at the forefront of research and teaching minimally invasive cataract surgery. Dr. Packard detailed the history of the capsulotomy in his lecture, explaining how the role of the capsular opening and the means of achieving it has changed. It has evolved from a roughly made tear to allow access to the nucleus for its extraction, to the creation of a more regular opening to allow support for intraocular lenses, to a continuous circular tear to help contain the IOL, to finally reaching precision in size and location with the laser and other technologies. The modern era of cataract surgery really begins with Jacques Daviel, he said, who pioneered the idea of removing the cataract from the eye in 1747 by opening the capsule and expressing the nucleus. Throughout the years, other pio- neers have changed techniques and discovered newer, more effective, and safer ways to perform capsulo- tomies. Cornelius Binkhorst, MD, for whom the Binkhorst Lecture is named, played a major role in the history of the capsulotomy. He thought it would be better to fixate the lens in the capsular bag, which would help eliminate the need for pupil involvement and led to the creation of his two-loop lens. Dr. Binkhorst also developed the "moustache lens." The continuous curvilinear capsulorhexis (CCC) was particu- larly influential in the field, and Dr. Packard said that Howard Gimbel, MD, Kimiya Shimizu, MD, and Thomas Neuhann, MD, all contrib- uted immensely to this. However, Calvin Fercho, MD, was likely the first surgeon to perform the CCC, although he's not known for popularizing the technique. What were the consequences of this new capsulotomy? The IOL could now be placed reliably and securely in the capsular bag; previous phaco Evolution of the capsulotomy Dr. Packard performing a posterior capsulorhexis on a pediatric case. Kloti high frequency radio-diathermy being used to perform a capsulotomy. source (all): Richard Packard, MD

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