This document discusses cataracts and cataract surgery. It provides an overview of cataract anatomy, symptoms, and surgery. It describes the risks factors for developing cataracts and recommendations for cataract screening and treatment. The document then focuses on how using a femtosecond laser during cataract surgery can improve precision for steps like corneal incisions, anterior capsulotomy, and lens fragmentation compared to traditional manual techniques. This precision is said to allow for more consistent outcomes and reduced risks.

1. Alan Solinsky, MD
David Jeng, MD

2. Overview
 The Anatomy
 The Symptoms
 The Surgery
 The Future

3. Anatomy

4. Risks
 Advanced age;
 A family history of cataracts;
 Extensive exposure to sunlight or UV light;
 Smoking;
 Diabetes, Obesity, High blood pressure;
 Long-term use of steroid medication (especially
combined use of oral and inhaled steroids)
 Previous eye injury or inflammation in the eye;
 Previous eye surgery

5. Symptoms
 Painless cloudy, blurry or dim vision
 More difficulty seeing at night or in low light
 Sensitivity to light and glare
 Seeing halos around lights
 Faded or yellowed colors
 The need for brighter light for reading and other
activities
 Frequent changes in eyeglass or contact lens
prescription
 Double vision within one eye

6. Remember
 Just because you have a cataract, does NOT mean you
need surgery
 Must weigh the risks and benefits of surgery for each
individual

7. Recommendations
 Have an eye exam every year if you're older than 65, or every two
years if younger.
 Protect your eyes from UV light by wearing sunglasses that block
at least 99 percent UV and a hat.
 If you smoke, quit. Smoking is a key risk factor for cataracts.
 Use brighter lights for reading and other activities; a magnifying
glass may be useful, too.
 Limit driving at night once night vision, halos or glare become
problems.
 Take care of any other health problems, especially diabetes.
 Get the right corrective lenses (glasses/contacts) to correct your
vision; when it becomes too difficult to complete your regular
activities, consider cataract surgery.

8. Cataract

9. Cataract Surgery

10. Corneal Incision

11. Capsular Opening

12. Removal of Cataract

13. Insertion of Intraocular Lens

14. Position of Intraocular Lens

15. Goals
 To remove the cataract
 To improve vision by implanting the correct
intraocular lens
 But, the standard lens would still require reading
glasses
 However, there are options to minimize dependence
on glasses

16. Premium Intraocular Lenses

17. Risks
 There are inherent risks in everything we do, especially
in medicine
 Cataract surgery is one of the safest surgeries available
 Technique has evolved and has been refined to
minimize risk

18. Common Question
 Is this laser surgery?
 No, this is not laser surgery
 But……….

19. The Future Is Now
 Bladeless, laser-assisted cataract surgery
 LenSx Laser System
 Same laser used for LASIK

20. Need for Improved Outcomes

21. What is a femtosecond laser?
 A laser that emits optical pulses with a duration in the
range of femtoseconds (1 fs = 10-15 seconds)
 Allows for precise cutting of tissue with minimal
collateral damage
 Utilized since 2001 in ophthalmologic procedures such
as LASIK, corneal transplants

22. Commercially Available Systems
 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)

23. Alcon LenSx

24. LenSx
 first femtosecond laser cleared by the FDA for use in
cataract surgery. It is indicated for:
 All corneal incisions
 Anterior capsulotomy
 Lens fragmentation
 The LenSx® Laser brings a new level of precision to these
surgical steps through a number of high-tech features:
 Real-time video imaging with integrated OCT. Provides
three-dimensional visualization of the entire anterior
segment during docking, planning and procedure.
 Curved patient interface. Designed for patient
comfort, ease of use and optimal laser performance.

25. How is a femtosecond laser used to
assist in cataract surgery?
 Currently, FDA-approved for 3 steps:
 All corneal incisions
 Anterior capsulotomy
 Lens fragmentation
 But, why is this important?

26. Limitations of Traditional Cataract
Surgery

27. Femtosecond Laser
 Offers a new level of precision and reproducibility in
ophthalmic surgery
 Helps to optimize the capsular and corneal incisions
1. Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at: Annual Meeting 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.

28. Real-Time Images

29. SoftFit Patient Interface
 A disposable, single-use, soft contact lens is used to dock
with the patient's eye.
 This curved patient interface is designed for patient
comfort, ease of use, and optimal laser performance.
 Surgeons guide and gently dock the disposable patient
interface using the video microscope and integrated real-
time OCT.
 The unique shape of the patient interface helps maintain a
more natural curvature of the patient's cornea. This helps
to improve surgical accuracy during the LenSx® Laser
procedure.

30. Manual Clear Corneal Incisions
 Imprecise tunnel length and geometry
 Frequently require stromal hydration to seal
wound, which induces corneal edema
 Poor wound construction may lead to snowball effect
of intraoperative difficulties (anterior chamber
maintenance and fluid dynamics)
 Incisions may be unstable, which may lead to
increased risk of infection
Behrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds after phacoemulsification
surgery using optical coherence tomography in the early postoperative period. J Refract Surg, 2008;24(1):46-9
Taban M, Behrens A. Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of literature.
Arch Ophthalmol. 2005;123(5):613-20

31. Manual Corneal Incisions

32. Laser Corneal Incisions

33. Astigmatism in Cataract Patients

34. Arcuate Incisions
 Manually created using
handheld diamond blade
 Inconsistent depth control
 Risk of perforating cornea
 Unpredictable effect due to
imprecise wound
architecture and depth
 No image-guided planning
or visualization

35. Laser Arcuate Incisions
 Image-guided surgical
planning with OCT
 Real time corneal thickness
 Computer-customized
incisions
 % depth
 Incision length and position
 3D visualization of incision
placement
 Predictable incision width
 Titratable incisions
(adjustable intraoperatively
and post-operatively in
office)

36. Laser Arcuate Incisions

37. Anterior Capsulotomy
 Continuous and perfectly curvilinear
 Potentially stronger with lower likelihood of anterior
capsular tears

38. Anterior Capsulotomies
Manual
Femtosecond Laser

39. Why does this matter?
Anterior Capsulotomy

40. Effective Lens Position

41. Effective Lens Position
“The key to highly accurate IOL power calculation is
being able to correctly predict ELP for any given
patient and IOL”
Studies show that the size of capsulorhexis affects ELP
Capsulorhexis needs to be round, centered, and just
smaller than the IOL optic diameter
Haigis W, Lege B, Miller N, Schneider B. Comparison of immersion ultrasound biometry and partial coherence interferometry
for IOL
calculation according to Haigis. Graefes Arch Clin Exp Ophthalmol, 2000;238:765-73
Cekic O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers,
1999;30(3):185-90
Hill WE. Hitting Emmetropia. Chang D. (ed) In: Mastering Refractive IOLs – The Art and Science. Slack, Incorporated, 2008
Hill WE. Does the Capsulorhexis Affect Refractive Outcomes? Chang D. (ed) In: Cataract Surgery Today, Bryn Mawr
Communications,
Wayne, Pennsylvania 2009, p.78

42. Capsulotomy
 Using the available laser systems, it is possible to
precisely center the capsulorhexis and determine the
diameter and depth of the anterior capsulotomy.

43. Lens Fragmentation
 The femtosecond laser performs lens
fragmentation, creating easily dissected segments for
efficient removal with reduced phaco power.
 Most systems allow the surgeon to set the lens
fragmentation pattern, from pie cuts to complete
liquefaction.

44. Lens Fragmentation
 Patterns can be customized for the cataract type
 Spares ultrasonic power and time

45. LenSx Laser System
 Image-guided femtosecond laser designed specifically
for refractive cataract surgery
 Using a customizable 3-D surgical platform, it allows
visualization, customization and completion of many
of the most challenging steps of cataract surgery:
 Anterior capsulotomy
 Lens fragmentation
 All corneal incisions

46. Laser-Assisted Cataract Surgery
More reproducible incisions
+ More precise positioning of capsulotomy
+ Less ultrasound energy needed
___________________________________
= More predictable outcomes