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EW CATARACT 83 April 2017 by Timothy P. Page, MD Capsulotomy speed, laser settings, and complete capsulotomy rate are all important factors to understand before using femtosecond lasers in complex eyes I n an eye with a white, intumes- cent cataract, there is always the risk of Argentinian flag sign, an unwanted complication in which hydrostatic pressure within the lens builds up and pushes outward on the lens capsule, causing a rapid tear-out during capsulotomy in the trypan-blue stained capsule that resembles the blue and white striped Argentinian flag (see Fig- ures 1 and 2). If the tear crosses the zonules, the posterior capsule may rupture, and the lens can be lost into the vitreous. Needless to say, this means sending the patient for vitrectomy and lens retrieval with the retina specialist and implanting the IOL in the sulcus. A recent case prompted me to consider the best approach in such eyes. The patient was a relatively young 56-year-old engineer with a 1-year history of blurred vision in the left eye. By the time I saw him, he had a white, intumescent cata- ract with hand motion vision. The cataract was idiopathic; he was not diabetic and had no known history of trauma or steroid use. I had to choose between a man- ual capsulorhexis with a cystotome, fluid aspiration with a 26-gauge needle or femtosecond laser capsu- lotomy. A technique has also been described in which the laser is used to create a 1.0-mm circular puncture through which the fluid can be aspi- rated with a blunt-tip cannula before enlarging the opening. 1 This patient had carefully researched cataract surgery options and had come to me specifically because I perform laser-assisted cataract surgery (LACS). He was highly motivated to have LACS, and a prospective case series of 25 eyes had recently been published, demonstrating that it is technically feasible to perform femtosecond laser capsulotomy in an eye with in- tumescent cataract. 2 However, I had to consider the potential for tags or an incomplete cap, which would be detrimental in this eye. At the time I had access to several different femto- second laser systems, each of which had strengths and weaknesses. I ultimately did perform LACS using the Catalys laser system (for- merly Abbott Medical Optics [AMO], now Johnson & Johnson Vision [J&J Vision, Santa Ana, California]) because of its ability to perform fast capsulotomies. The patient had an excellent outcome. But it got me Femtosecond laser capsulotomy in intumescent cataract Performing Cataract Surgeries? ECP Course with Hands-on Wet Lab Location: JW Marriott Room: Atrium III Date: Saturday, May 6 Time: 5:30 - 7:30pm Registration and refreshments at 5:30 NEW! In-Booth Clinical Wet Lab During ASCRS show hours at: BVI Booth 2613 1-866-906-8080 beaver-visitec.com A complete portfolio of ophthalmic products * Francis, B., Berke, S., Dustin, L. and Noecker, R. (2014). Endoscopic cyclophotocoagulation combined with phacoemulsification versus phacoemulsification alone in medically controlled glaucoma. Journal of Cataract & Refractive Surgery, 40(8), pp.1313—1321. Pair your procedure with Endoscopic CycloPhotocoagulation (ECP) and effectively improve the surgical outcome of your glaucoma patients. ECP added to cataract extraction resulted in greater reduction in IOP and glaucoma medications than cataract extraction alone over a 3 year period.* Endo Optiks® Laser Microendoscopy System Attend one of our Endo Optiks® Wet Labs during ASCRS REGISTER ONLINE NOW endooptiks.com continued on page 84 Watch a video of this case now at EyeWorld Clinical rePlay clinical.ewreplay.org

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