Eyeworld

EW CATARACT 28 August 2016 by Liz Hillman EyeWorld Staff Writer Tips and tricks level and you're grabbing onto grav- el instead of solid rock and you keep pulling gravel off. You never actually get a handhold to pull yourself up," Dr. Scott said, giving an analogy of what it's like to use a peristaltic setting on a femto-treated eye. "If you anticipate that and convert to venturi, then the pieces are always coming toward you at least. You're controlling the vacuum." Dr. Scott said that he doesn't do hydrodissection in FLACS cases un- less it is a softer lens with difficult to remove subincisional quadrants. He went on to say that the most import- ant step in a FLACS case, from an efficiency standpoint, is to split the lens in two. He first tries viscoelastic in the central soft segment line, a technique he called endolenticular viscodissection. If that doesn't work, he'll use two instruments in this same area, drawing them toward each other to split the lens. Dr. Waring said his preferred technique is to hydrodissect using preservative-free lidocaine and epi- nephrine. "My feeling is I may get some chemical cleavage of the cortex," he said. Drs. Waring and Scott said they polish the capsule in both FLACS and standard phaco cases. One of the nuances of FLACS vs. standard phaco is cortical removal. In standard phaco cataract surgery, Dr. Waring said fimbrications of the cortex are present and are generally loose and easy to grab. Due to the perfect capsulotomy and "anterior cortexotomy" made by the laser and other thermal/mechanical factors that may compress the cortex in FLACS, those fimbrications are lost. Dr. Waring said, however, that after some practice it's not too different from routine cortex removal. Factoring in flow The techniques are just one consid- eration when adopting femto. Flow is another. "Incorporating it into your flow does require some pre-planning for a surgery day," Dr. Waring said. "For example, we ran two surgical rooms and then had the laser in a third room. So we would just toggle back Tips and tricks Starting out with femto is "just a matter of understanding a few tips and tricks, mostly centered around nuclear disassembly, depending on your technique and laser settings, and cortex removal," Dr. Waring said. Preparing for the difference the femtosecond laser posed to nuclear disassembly, Dr. Scott said his prac- tice, which brought in two Catalys lasers in 2013, made adjustments in their procedures several months before beginning to use the lasers. This transition involved switching from the peristaltic pump system to venturi. Comparing the femtosecond- treated lens to a rock that has been crushed into bits of gravel, Dr. Scott explained that if a surgeon were to use a peristaltic setting, he or she would likely find that the little piec- es keep breaking off. "[Imagine] you are rock climb- ing and you reach up to the next Storm Eye Institute, Medical Univer- sity of South Carolina, and medi- cal director, Magill Vision Center, Charleston, South Carolina, and Wendell Scott, MD, Mercy Clinic Eye Specialists, Springfield, Missou- ri, offered some tips and tricks for adapting traditional cataract surgery techniques as seamlessly as possible when switching to femto. "One of the things that we always tell people who are adopting this technology is that there are multiple facets to adoption," said Dr. Waring, who has used the femtosec- ond laser—the Catalys Precision La- ser System (Abbott Medical Optics, Abbott Park, Illinois)—for more than three years. "It's not just a new piece of equipment; there are flow consid- erations, there are patient education considerations. Of course there are some minor surgical technique mod- ifications. Then there is understand- ing all the benefits that the laser has to offer, becoming comfortable with it, and using the technology to its fullest extent." Tips for those new to femtosecond laser- assisted cataract surgery W hile some ophthal- mologists have already adopted the femtosecond laser into their cataract surgery practice, there are many who are just starting out or still considering whether to bring on this technology. An audience poll with 70 par- ticipants at the 2016 ASCRS•ASOA Symposium & Congress found, for example, that about 38% said they already use the femtosecond laser in cataract surgery, while about 7% said they are going to order a machine this year, and about 33% said they are still unsure about the practice. For those new to femtosec- ond laser-assisted cataract surgery (FLACS), George Waring IV, MD, associate professor of ophthalmol- ogy, director of refractive surgery, Adapting your standard phaco technique for FLACS Dr. Scott has been performing FLACS for two years and in that time has learned to adjust his phaco techniques for working on a femtosecond laser-treated eye. Source: Wendell Scott, MD

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