Eyeworld

5 5 Supported by Abbott Medical Optics and Bausch + Lomb by William Trattler, MD Examining routine and complex cataract cases: Determining factors of an LACS candidate After I open the incision, I ensure that the capsulotomy is free all of the way around, using a circular motion. Hydrodissection is a critical step. We first need to be sure the capsular bag is not overfilled with viscoelastic, so at times we may press on the lip of the incision and release excess viscoelastic. Once the eye is not too firm, we can gently perform the hydrodissection. LACS candidates In my opinion, almost all patients can benefit from LACS technolo- gy. It creates a perfectly centered capsulotomy, and I can make an effective, self-sealing incision. Aforementioned studies and my experiences have shown that patients with dense cataracts may particularly benefit from LACS. It is important to point out that performing femto cataract surgery is a bit different than manual cat- aract surgery, so there is a bit of a learning curve with benefits and risks associated. However, with experience, I think that many surgeons will appreciate how laser cataract surgery can make the LACS: My pearls for success During LACS, we first make sure the pupils are dilated so we can ensure clear imaging after the cataract. Although the laser has a tracker, the procedure is easier if the patient remains still during the procedure. When the laser procedure is completed, we place the patient under the operating microscope. After I create the paracentesis, I inject a little preservative-free anesthetic and place viscoelastic on top of the capsule so there is no shallowing of the anterior chamber. I keep the chamber deep the entire time. If an area of the capsulotomy is incomplete and the chamber shallows, there is a risk that the nucleus pushes for- ward, which can tear the capsule. One innovation with femto cataract surgery is the main incision, which can be created to be self-sealing. The femtosecond laser system that I use creates a reverse-angle incision, which is more like a tongue-and-groove incision and results in a more self-sealing incision than that typ- ically created with a metal blade. without exerting stress. The femtosecond laser helps reduce transferred energy into the eye during phacoemulsification, thus less zonular stress. 3,4 Some surgeons use manual techniques in certain situations, such as posterior capsular cataract (PSC) or a PSC that is very soft. They may take this approach if the case appears very easy and the patient has chosen a monofocal IOL, where a perfectly centered capsulotomy may not be as critical. Patients with very small pupils may not be eligible for treatment with the femtosecond laser because the technology cannot image the anterior capsule through the iris. Therefore, in eyes with very small pupils and thus a smaller lens surface, the laser may not be able to perform the capsulotomy or soften the lens. 5 Nuclear fragmentation Nuclear fragmentation with LACS enables surgeons to choose a fragmentation pattern for the nucleus. 6 As we sculpt into the nucleus, we can see where the laser treated, and it provides a road map guiding us on where to stop sculpting. We can determine when we are very close to the end of the nucleus (and approach- ing the posterior capsule) based on the pattern. After sculpting through the nucleus, we can easily crack the lens, which makes it much easier to manage dense lenses. With exceptionally dense lenses, the imaging technology may not be able to image the posterior capsule and the laser may only be able to perform the anterior capsulotomy and soften the front part of the lens. However, a centered capsulotomy makes it easier to perform surgery, particularly with a dense lens. Laser-assisted cataract surgery offers practical advantages in most patients I n my experience, laser-assist- ed cataract surgery (LACS) is a valuable tool in a variety of patients, whether they are receiving multifocal intraoc- ular lenses (IOLs), toric IOLs, or monofocal IOLs. Its advantages also extend to more complicated cases, such as pseudoexfoliation or very dense cataracts. 1 LACS: Patient selection pearls One of the best features of LACS is its ability to create a centered, more precise capsulotomy 2 (Figure 1). My laser system provides a 3D image of the capsular bag, deter- mines the center of the cataract to centrally place the capsulotomy, and creates a perfect circle. This helps when I am implanting a multifocal or toric IOL, as I want to ensure that the IOL is centered and the anterior capsule leaflets overlap the IOL. LACS is also helpful in patients with loose zonules in pseudoexfoliation because the capsulotomy is performed William Trattler, MD continued on page 6 " LACS is also helpful in patients with loose zonules in pseudoexfoliation because the capsulotomy is performed without exerting stress. " –William Trattler, MD

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