Current and latest results of Femtosecond cataract surgery, procedure overview, patient experience, advantages and disadvantages

1. 1
FEMTOLASER CATARACT SURGERY
Something to think about
Dr Ross Ferrier
Gosford and Wyong Eye Clinics

2. Manual Cataract Surgery Today
 2 temporal clear corneal incisions
 Create a 6mm opening in the lens capsule (capsulorhexis)
that is as circular and central as possible
 Fragment the clouded lens with surgical instruments and
ultrasound energy
 Carefully remove all remaining lens cells with aspiration
 An artificial intraocular lens (IOL) is then placed in the
capsular bag and positioned as necessary

3. CORNEAL INCISIONS
 Not optimised
 Variable degree of entry
 Variable resulting astigmatism
 Variable degree of infection risk and iris prolapse from
wound leak

4. CAPSULORHEXIS
 Variable
 Shape
 Size
 Location on axis
 Effects on the position of the implant

5. LENS FRAGMENTATION
 Variable technique
 Chop
 Stop and chop
 Divide and conquer
 Lens flip
 Aim to remove the lens with the lowest possible
energy and the lowest risk to the corneal
endothelium

6. ASPIRATION
Remove as much of the remaining
lens cell population as is possible to
minimise the risk of capsule
fibrosis and posterior capsule
opacity

7. WHY LASER CATARACT SURGERY?

8. Femtosecond laser
 Femtosec laser causes tissue disruption with its
near-infrared scanning pulse focused to 3um with
an accuracy of 1um
 The focused laser energy generates plasma which
expands, causing a shock wave, cavitation and
bubble formation
 The bubble expands and collapses causing
separation of the tissue
 No heat damage due to laser properties.

9. Advantages
 Precise programmable
corneal incisions
 Accurate capsulorhexis
size, shape and
centration
 Reduction in power
and time with unique
fragmentation patterns
 Arcuate incisions

10. Manual vs. Femtocataract Surgery – 1 month
postop
Manual Surgery Femtocat Surgery
MK-00251 Rev A

11. More predictable outcomes
More predictable shape
? Better outcomes
Catalys Clinical Results:
Capsulotomy Shape
Manual Capsulorhexis
Catalys Capsulotomy
MK-00251 Rev AImages courtesy of OptiMedica Corp.

12. Catalys Clinical Results:
Capsulotomy Size
Manual (Mean SD) Catalys (Mean SD)
Deviation from
intended
diameter
339 μm 248μm 29 μm 26 μm (p<0.001)
Manual (N = 29) Catalys (N =39)
0
200
400
600
800
1000
1200
Deviationfromintendeddiameter(μm)
0
200
400
600
800
1000
1200
For comparison, the width of a human hair is approximately 85-100 microns.
MK-00251 Rev AData courtesy of OptiMedica Corp.

13. Laser
Fragmentation
Mechanism of
Action
Chop Patterns Cylinder Patterns
LSX11512SK
15

14. OR microscope view
MK-00185 Rev B MK-00251 Rev AImages courtesy of OptiMedica

15. LenSx® Laser Phacofragmentation
• Cylinder pattern, utlilized for the softer lens, enables removal with
I & A only, no phaco power
• Chop pattern efficiently fragments the lens for removal with
reduced phaco power and time1
43% reduction51% reduction
1Nagy ZZ, Takacs A, Filkorn T, Sarayba M, Initial Clinical Evaluation of an Intraocular Femtosecond Laser in Cataract
Surgery, Journal of Refractive Surgery, 2009;25:1053-1060.
LSX11512SK
16
0
0.2
0.4
0.6
0.8
1
1.2
1.4
EffectivePhacoTime(min)
Comparison of Effective Phaco Time
Phaco only
Laser plus
Phaco
0
5
10
15
20
25
30
AveragePower(%)
Comparison of Average Phaco Power
Phaco only
Laser plus
Phaco

16. EffectivePhacoTime(seconds)
LOCS II
Catalys
LOCS III
Catalys
LOCS IV / IV+
Catalys
LOCS II
Standard
LOCS III
Standard
LOCS IV
Standard
LOCS II:
Standard
II: Femto III:
Standard
III: Femto IV:
Standard
IV/IV+:
Femto
EPZ
(s)
1.96 1.29 0.02 0.05 3.32 1.83 0.10 0.16 6.21 3.68 0.24 0.25
Catalys Clinical Results:
Impact on Effective Phaco Time
n= 13 n= 10 n= 18 n= 19 n= 21 n= 28
Data courtesy of Prof. Burkhard Dick, MD, PhD. Ruhr University Eye Hospital. Bochum, Germany, Member of
OptiMedica Medical Advisory Board. MK-00251 Rev A

17. Catalys treatment of LOCS grade4+ cataract
MK-00185 Rev B MK-00251 Rev A
Images courtesy of OptiMedica

18. Manual Arcuate Incisions
 Manually executed by
“tracing”
corneal marks with
handheld diamond
knife
 Inconsistent depth
control
 Unpredictable effect as
is imprecise
19

19. Laser Arcuate Incisions
Image-guided surgical
planning with 3D
visualization:
 Real time corneal thickness
 Computer programmed
incisions
- % depth
- incision length and position
- 3D visualization of incision
placement
20

20. Laser Arcuate Incision
• Square edge
• Uniform depth (no ripples)
• Precise, reproducible
– Arc shape
– Arc length
– Diameter
Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing
Incisions, ASCRS 2010, Boston
LSX11512SK
21

21. PROCEDURE OVERVIEW

22. Technique
 Performed under LA with speculum
 Mydriasis
 Patient looks at fixation lights
 Laser is docked

23. Catalys 4-Step Procedure Overview
MK-00251 Rev A

24. Treatment Planning
MK-00185 Rev B MK-00251 Rev A

25. PLAN Procedure with Templates
Quick, template based planning performed prior to patient
MK-00251 Rev A

26. Patient Positioning
MK-00185 Rev B MK-00251 Rev A

27. ENGAGE with Liquid Optics™ Interface
• Gentle dock for patient with minimal intraocular pressure (IOP) rise and
minimal hemorrhaging
• No corneal distortion or induced folds
• Clear optical path for precise imaging and laser delivery
Liquid Optics Suction
Ring
Liquid Optics Docking
Liquid Optics Advantage: Optical and comfort gains
Catalys OCT with Liquid
Optics
MK-00185 Rev B MK-00251 Rev A

28. VISUALIZE and CUSTOMIZE with
Integral Guidance™
• Integrated near-infrared video and 3D spectral domain OCT systems
visualize from anterior cornea through posterior lens
• Sophisticated algorithms customize treatment plan in 3D to anatomy of
each patient
Catalys 3D spectral domain OCT
MK-00185 Rev B
Ocular surfaces mapped and treatment
customized even when lens is tilted
MK-00251 Rev A

29. MK-00251 Rev A

30. System features – comparative view
Feature Catalys
(OptiMedica)
(Designs for
Vision)
LenSx
(Alcon)
LensAR
(IQMedical)
Technolas
(B&L)
Interface Design Liquid Optics™
Interface
Curved
Applanation
Lens
Robocone™
(Immersion
Lens)
Curved
Applanation
Lens
Imaging Type 3D spectral
domain OCT
3D OCT 3D-CSI
(confocal
structured
illumination)
Online OCT
Ocular Surface
Identification
Automatic or
user-
adjustable
Manual Automatic Manual
System Origin Laser Cataract
Surgery
Femtosecond
LASIK
(Intralase)
Presbyopia
Treatment
Femtosecond
LASIK
MK-00185 Rev B

31. PART TWO: TO THE CAT CAVE!
 The patient is prepared for the lens extraction as per
routine procedure.
 The prepared wound is opened
 Viscoelastic injected
 Capsulorhexis carefully removed
 Careful hydrodissection
 Phacoemulsification
 Aspiration and cleaning of capsule
 Lens insertion

32. Patient Experience
Clinical Workup
No major changes to standard
procedure
Things to note:
 How well patient dilates
 Is patient able to keep still during
procedure

33. Patient Experience
 During procedure
 Docking: Slight pressure from vacuum pressure
of interface (no pain or loss of vision)
 During laser: A kaleidoscope of lights as the
procedure occurs
 Immediate to One-Day Post-op
 Same regimen as existing practices
 Visual recovery may be faster because of
reduced ultrasound energy
 Patient may notice slight haemorrhaging on the
conjunctiva

34. Contraindications
 Femtocat is contraindicated in patients with corneal ring
and/or inlay implant(s)
 In patients with severe corneal opacities, corneal
abnormalities, significant corneal edema or diminished
aqueous clarity that obscures OCT imaging of the
anterior lens capsule
 Technical difficulties such as small pupil, deep orbit, very
shallow AC, dementia, tremor
 ? Paediatrics

35. Potential Advantages
 Accurate capsulorhexis size, shape and centration may
allow for better positioning of all implant types.
 Precise incisions to tens of microns: Astigmatism
control, infection control, iris prolapse reduction.
 Reduction in phako power and time should give less
endothelial cell loss, decreased risk of corneal oedema
 Numerous unique fragmentation pattern options allow
for treatment customization
 Arcuate incisions

36. Disadvantages
 Expensive ! Cost passed on to patient. “Value Add”
 Increased complexity!
 Increased duration!
 No evidence as yet that the increased predictability
which this expensive complex longer procedure
provides actually delivers a clinically superior
result over current techniques to justify its wide
acceptance
 Inapplicable in many demographic situations

37. Is it the future?

38. Statements : True or False
 Each step of current manual cataract surgery is
optimised , predictable and consistent
 Femtosecond laser uses short wavelength UV light
 Femtolaser cataract surgery is not contraindicated in
patients with small pupils, deep orbits or shallow
anterior chambers
38