This course provides an overview of howfemtosecond lasers can and will benefitpatients with cataracts and astigmatism.
To understand the uses of the femtosecondlaser To review the features of various systems andspecifically the Alcon LenSx® Laser To review the evidence in support of thefunctionality of femtosecond lasers To recognize the benefit of the femtosecondlaser in cataract surgery
Neither Alan Solinsky nor David Jeng has directfinancial or proprietary interest in any of thecompanies or services mentioned in thispresentation Neither Alan Solinsky nor David Jeng has receivedcommercial support from any of the mentionedcompanies Alan Solinsky is affiliated with Allergan as aspeaker. The content and format of this course may reflectcommercial bias BUT it does not claim superiorityof any commercial product or service
Earlier diagnosis and treatment beforesubstantial vision loss Baby Boomer patients demanding high qualitypost-operative vision New surgical approaches and lens implantsavailable to improve UCVA for many patients
A laser that emits optical pulses with aduration in the range of femtoseconds (1 fs =10-15 seconds) Allows for precise cutting of tissue withminimal collateral damage Utilized since 2001 in ophthalmologicprocedures such as LASIK, corneal transplants
Alcon LenSx® (approved for all steps) LensAR® system (approved for all steps) OptiMedica Catalys® (approved for all steps) B+L Victus® (approved for corneal flaps,incisions and anterior capsulotomy) AMO Intralase® FS (used in LASIK flaps,approved for arcuate incisions only)
Liquid Optics™ Interface Integral Guidance™ Attached ergonomic surgical chair
Augmented Reality™ Optical ray-tracing (Schleimpflug imaging) Lens Tilt detection Small footprint and Articulating arm mayallow for positioning in one operating room
Allows for LASIK flap creation and cornealincisions
The LenSx® Laser was the first femtosecond lasercleared by the FDA for use in cataract surgery. It isindicated for: Anterior capsulotomy Lens fragmentation All corneal incisions The LenSx® Laser brings a new level of precision tothese surgical steps through a number of high-techfeatures: Real-time video imaging with integrated OCT.Provides three-dimensional visualization of the entireanterior segment during docking, planning andprocedure. Curved patient interface. Designed for patientcomfort, ease of use and optimal laser performance. Intuitive touch screen graphic user interface. Allowseach step of the procedure to be easily planned,customized and executed. True image-guided surgical planning. Enables thesurgeon to precisely program the size, shape andlocation of each incision.
Currently, FDA-approved for 3 steps: All corneal incisions Anterior capsulotomy Lens fragmentation But, why is this important?
Offers a new level of precision andreproducibility in ophthalmic surgery Helps to optimize the capsular and cornealincisions1. Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at: AnnualMeeting of the American Academy of Ophthalmology; October 24-27, 2009;2. Nagy, ZZ. Intraocular femtosecond laser applications in cataract surgery. Cataract & Refractive Surgery Today. September 2009:79-82. San Francisco, CA.
LenSx® features an onboard, proprietary opticalcoherence tomographer (OCT) in conjunction witha video microscope, to provide three-dimensionalvisualization of the anterior segment. It canvisualize multiple views, including: Side View, Capsular Bag Topographic View, Lens Side View, Cornea
Catalys also includes integrated OCT LensAR uses ray-tracing technology for 3Dvisualization
A disposable, single-use, soft contact lens is used to dock with thepatients eye. This curved patient interface is designed for patient comfort, easeof use, and optimal laser performance. Surgeons guide and gently dock the disposable patient interfaceusing the video microscope and integrated real-time OCT. The unique shape of the patient interface helps maintain a morenatural curvature of the patients cornea. This helps to improvesurgical accuracy during the LenSx® Laser procedure.
Both Catalys and LensAR have a low-pressurefluid-filled docking system
Imprecise tunnel length and geometry Frequently require stromal hydration to sealwound, which induces corneal edema Poor wound construction may lead to snowballeffect of intraoperative difficulties (anteriorchamber maintenance and fluid dynamics) Incisions may be unstable, which may lead toincreased risk of infectionBehrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds afterphacoemulsification surgeryusing optical coherence tomography in the early postoperative period. J Refract Surg, 2008;24(1):46-9Taban M, Behrens A. Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review ofliterature. ArchOphthalmol. 2005;123(5):613-20
Primary and secondary incisions (includingarcuate incisions) can be created Size and degree of each incision and itsorientation are customizableSingle-plane cutTwo-plane cutThree-plane cut
Manually created usinghandheld diamondblade Inconsistent depthcontrol Risk of perforatingcornea Unpredictable effectdue to imprecise woundarchitecture and depth No image-guidedplanning orvisualization
Image-guided surgicalplanning with OCT Real time corneal thickness Computer-customizedincisions % depth Incision length and position 3D visualization of incisionplacement Predictable incision width Titratable incisions(adjustable intraoperativelyand post-operatively inoffice)
Continuous and perfectly curvilinear Potentially stronger with lower likelihood ofanterior capsular tears
Only 10% of manually created capsulorhexisachieved a similar diameter accuracy of +/-0.25mm vs. nearly 100% of LenSx proceduresNagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at:AnnualMeeting of the American Academy of Ophthalmology; October 24-27, 2009; San Francisco, CA.Nagy, ZZ. Intraocular femtosecond laser applications in cataract surgery. Cataract & Refractive Surgery Today. September2009:79-82.
“The key to highly accurate IOL powercalculation is being able to correctly predictELP for any given patient and IOL”Studies show that the size of capsulorhexis affectsELPCapsulorhexis needs to be round, centered, andjust smaller than the IOL optic diameterHaigis W, Lege B, Miller N, Schneider B. Comparison of immersion ultrasound biometry and partial coherenceinterferometry for IOLcalculation according to Haigis. Graefes Arch Clin Exp Ophthalmol, 2000;238:765-73Cekic O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic SurgLasers,1999;30(3):185-90Hill WE. Hitting Emmetropia. Chang D. (ed) In: Mastering Refractive IOLs – The Art and Science. Slack, Incorporated,2008Hill WE. Does the Capsulorhexis Affect Refractive Outcomes? Chang D. (ed) In: Cataract Surgery Today, Bryn MawrCommunications,Wayne, Pennsylvania 2009, p.78
Using the available laser systems, it is possibleto precisely center the capsulorhexis anddetermine the diameter and depth of theanterior capsulotomy.
Non-randomized, prospective, single site, singlesurgeon study With single lens type, ALCON monofocal SN60WF Manual group (n=26) Attempted 5.0mm manual capsulotomy LenSx Laser group (n=22) Femtosecond laser created 5.0mm capsulotomy Accuracy to Target, Actual ELP No significant difference in baseline betweencohortsRobert J Cionni MD. Presented AAO 2011 Refractive Sub-Specialty Day, “Comparison of Effective Lens Position and RefractiveOutcome:Femtosecond Laser vs Manual Capsulotomy”
The femtosecond laser performs lensfragmentation, creating easily dissectedsegments for efficient removal with reducedphaco power. Most systems allow the surgeon to set the lensfragmentation pattern, from pie cuts tocomplete liquefaction.
Patterns can be customized for the cataracttype Spares ultrasonic power and time
Ecsedy M, Miháltz K, Kovács I, Takács A, Filkorn T, Nagy ZZ, Effect of FemtosecondLaser CataractSurgery on the Macula, Journal of Refractive Surgery, 2011;27:717-722.Miháltz K, Knorz MC, Alio JL, Takács A, Kránitz K, Kovács I, Nagy ZZ, InternalAberrations andOptical Quality After Femtosecond Laser Anterior Capsulotomy in CataractSurgery, Journal of Refractive Surgery, 2011;27:711-716.Nagy ZZ, Kránitz K, Takács A, Miháltz K, Kovács I, Knorz MC, Comparison ofIntraocular LensDecentration Parameters After Femtosecond and Manual Capsulotomies, Journalof Refractive Surgery, 2011;27:565-569.Kránitz K, Takács A, Miháltz K, Kovács I, Knorz MC, Nagy ZZ, Femtosecond LaserCapsulotomy andManual Continuous Curvilinear Capsulorrhexis Parameters and Their Effects onIntraocular Lens Centration, Journal of Refractive Surgery, 2011;27:559-563.Nagy ZZ, Takács A, Filkorn T, Sarayba M, Initial Clinical Evaluation of an IntraocularFemtosecondLaser in Cataract Surgery, Journal of Refractive Surgery, 2009;25:1053-1060
Image-guided femtosecond laser designedspecifically for refractive cataract surgery Using a customizable 3-D surgical platform, itallows visualization, customization andcompletion of many of the most challengingsteps of cataract surgery: Anterior capsulotomy Lens fragmentation All corneal incisions