Eyeworld

39 Supported by unrestricted educational grants from Alcon Laboratories and Abbott Medical Optics Vance Thompson, MD by Vance Thompson, MD Weighing the impact of laser- assisted cataract surgery To determine the best course of action, we consider the patient's age, symptoms, and findings from the slit lamp examination. In addition, diagnostic advances allow us to quantify our findings. One technology I use is the HD Analyzer, which uses a double-pass method of measuring forward scat- ter, the same scatter the patient sees. iTrace technology also is helpful in pinpointing whether the problem is in the lens or cornea. The Pentacam allows me to quantify lens density in an early cataract situation. Patients are learning more about advances in laser-assisted cata- ract surgery (LACS) and premium implants on the Internet and ask us which option is best. To help them make this decision I ask them: What vision do you want? Do you want to use glasses for most of your activities or would you prefer to go without glasses for most of your activities? These questions generate a good discussion about the vision they seek and the technology that gives me the most confidence to help them achieve their goals. Financial considerations Surgeons who are interested in providing premium technology may be daunted by the financial aspects. Although they understand how to manage the therapeutic insurance- based part of cataract surgery, the refractive part, which patients pay for, may be intimidating. It can be complicated because additional tests and technology are required preoperatively, intraoperatively, and postoperatively. W hen weighing the in- tegration of premium technology into their practices, surgeons need to consider its impact on their practices. Pinpointing the problem When we discuss the aging lens with patients, I find it helpful to talk about dysfunctional lens syndrome. The first stage is presbyopia, when the lens is still clear but has lost its flexibility, and the third is when the lens is cloudy and has lost its flexibility. However, in the second stage, when the lens is yellow and hazy, the term dysfunctional lens syndrome can be especially helpful. Figure 1. Weighing the benefits of fixed-access versus transportable access Transportable access "Pay as you grow" • Transportable access on alternate weeks • Experienced laser engineer/operator • Keep pace with demands of market 10 to 20 cases/month Fixed access "Maximizing your ROI" • Fixed laser available for all surgeries • Facility staff are laser operators • Market share growth strategy >20 cases/month continued on page 40 effect, decrease the grid spacing in- terval with increasing lens density. 6. Phaco technique: Recognize that femtosecond mini chop provides easier vertical chop. There is no need to sculpt or groove after femto segmentation/ softening. The chopper is used only to separate the pre-segmented quad- rants as the phaco holds. I use this technique for 2++ NS and greater lens densities. Aspiration-driven lens removal takes center stage in femto phaco. Nevertheless, my goal is not zero phacoemulsification; it is zero com- plications. 7. Phaco technique: Realize that "femto flip" is a safer and easier supracap technique. The supracapsular phaco tech- nique has been shown to be safe and effective, but with LACS femto flip is even safer. I use this for 2+ NS and less dense nuclei. With a 5.3-mm capsulotomy and following femto softening, this femto flip technique is typically performed with the epi- nucleus setting, resulting in minimal phaco energy, decreased fluid use, and increased safety. 8. Capsulotomy in small pupil: Have a small pupil strategy. For small pupils, I encourage everyone to use phenylephrine 10% drops preoperatively, if not medi- cally contraindicated. I advise each surgeon to have in mind a mini- mum acceptable capsulotomy size (i.e., >4.5 mm). For smaller pupils, one can suppress the capsulotomy and still perform the fragmentation. 9. Fragmentation without capsu- lotomy: Know how to respond to small pupil, dense lens. In cases with a small pupil and dense lens, I suppress the capsulot- omy and selectively continue with femto fragmentation (off-label use). Then I perform a manual capsulor- hexis after viscodissection, pupil stretch, or ring placement. In the many cases where I have performed fragmentation without capsulotomy, I have not witnessed any significant- ly increased intralenticular pressure. 10. I/A: Use silicone tip, single-use I/A. A flexible, single-use silicone tip I/A is safer and easier for the stickier cortex in femto phaco. Furthermore, a soft silicone port allows worry-free polishing of the subincisional space, posterior capsule, and anterior cap- sular rim. Although it costs more, this is a premium procedure requir- ing premium technology. Conclusion When using LACS, we need to know how to make the most of femtosec- ond laser technology to achieve the best surgical outcomes. Dr. Raviv is clinical associate professor of ophthalmology, Icahn School of Medicine, Mount Sinai, and founder and medical director, Eye Center of New York. Figure 1. Using LACS, surgeons can customize the fragmentation pattern to the lens density. continued from page 38

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