This document discusses femtosecond laser-assisted cataract surgery (FLACS). It describes how femtosecond lasers work using ultrashort pulses to precisely cut tissue with minimal collateral damage. The major advantages of FLACS include reduced ultrasound energy needed for phacoemulsification and more precise capsulotomies and incisions. However, risks include increased anterior capsule tears due to the learning curve. The document also discusses techniques for managing complications like posterior capsule rupture, including performing limited anterior vitrectomy through the capsular opening or pars plana vitrectomy ports.

1. AJAY I DUDANI
MUMBAI RETINA CENTRE
ZEN EYE CENTRE

2.  Current femtosecond laser technology
systems use neodymium:glass 1053 nm
(near-infrared) wavelength light.
 The focused ultrashort pulses eliminate the
collateral damage of surrounding tissues and
the heat generation.

3. Photodisruption :
 Femtosecond laser energy is absorbed by the
tissue, resulting in plasma formation.
 This plasma of free electrons and ionized
molecules rapidly expands, creating
cavitation bubbles.
 The force of the cavitation bubble creation
separates the tissue.

5.  The major advantage of FLACS is the
reduction of phacoemulsification energy
required in the surgery.
 Nuclear fragmentation before
phacoemulsification significantly reduces the
amount of ultrasound energy and effective
phacoemulsification time (EPT) required in the
surgery

6.  More circular and precise capsulorrhexisand
IOL implantation, and offer more accurate
refractive outcomes after surgery.
 less endothelial cell loss
 precise corneal incisions

8.  Anterior capsule tears is the most common
intraoperative complication for FLACS
 postage-stamp perforations and additional
aberrant pulses, possibly because of fixational
eye movements
 Increased incidence due to higher learning curve
 expensive,
 increased anterior chamber prostaglandin levels
-Abell RG, et al. Anterior capsulotomy integrity after femtosecond laser-assisted
cataract surgery. Ophthalmology. 2014;121:1724.
- Bartlett JD, et al. The economics of femtosecond laser-assisted cataract surgery.
Curr Opin Ophthalmol. 2016;27:7681.
-Schultz T, et al. Changes in prostaglandin levels in patients undergoing
femtosecond laser-assisted cataract surgery. J Refract Surg. 2013;29:7427

9.  can carry significant risk of posterior capsule
rupture with potential loss of lens material in
the vitreous and vitreous loss.
 Factors affecting include small capsulorhexis
and the surgeon's level of experience during
the fragmentation of the cataract

10.  Femtosecond lens fragmentation leads to the
production of intralenticular and
intracapsular gas.
 may lead to an increase in volume and
pressure which can result in intra-operative
posterior capsule rupture.

12. Roberts et al. reported adjustments –
 reducing the viscoelastics fill prior to anterior
capsule removal
 splitting the hemispheres prior to
hydrodissection
 decompressing the anterior chamber before and
during hydrodissection and the lens capsule
during hydrodissection
 and performing a slow and titrated
hydrodissection
Roberts TV, Sutton G, Lawless MA, Jindal-Bali S & Hodge
C (2011): Capsular block syndrome associated with femtosecond
laser-assisted cataract surgery. J Cataract Refract Surg 37: 2068–
2070.

13. Nagy et al. Suggested
 ‘rock-and-roll’ technique to avoid capsular
block syndrome –
 a gentle hydrodissection
 during hydrodissection, the surgeon should
gently press down the nucleus and turn it
around in order to allow the gas bubbles to
leave the eye towards the anterior chamber.
Nagy Z, Takacs A, Filkorn T & Sarayba M (2009): Initial clinical
evaluation of an intraocular femtosecond laser in cataract surgery. J
Refract Surg 25: 1053–1060.

14.  Abell et al. showed similar rates of posterior
capsular rupture and dropped nuclei with
FLACS and Manual phaco
 yet FLACS had a statistically significant
increased rate of anterior capsular tears
compared to manual phaco

15. Complications Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4 Surgeon 5 Total
None 25 130 60 38 20 273
Descemet's membrane
detachment
0 1 0 0 0 1
Lens material in
vitreous
0 0 0 0 0 0
Posterior capsule open 0 0 0 2 0 2
Significant anterior
chamber hemorrhage
0 0 0 0 0 0
Significant iris damage 0 0 0 0 0 0
Vitreous loss 0 0 0 0 0 0
Zonular dehiscence 0 0 0 0 0 0
Corneal abrasion 0 2 0 0 0 2
Total complications 0 3 0 2 0 5
Complication rate (%) 0 2.4 0 5.3 0 1.8
Table 1
Complications of laser-assisted cataract surgery

16.  Despite a multitude of studies, no study has
proven FLACS to be superior to manual phaco
with respect to clinical outcomes
 Visual benefits of FLACS over and above
manual phaco needs to be conclusively
demonstrated.
 FLACS remains ‘not’ cost-effective.
 FLACS is associated with a considerable
learning curve

17.  ONLY ONE CASE OF NUCLEUS DROP
 LEARNING CURVE
 OCT GUIDANCE IS PERFECT
 MULTIPLE CHIPS SCATTERED
 CAREFUL LENSECTOMY
 3 PORT 23G PPV

18. Anterior Vitrectomy
following Posterior Capsular Rupture

19.  Most frequent significant complication
encountered by Phaco surgeons in their learning
curve
 Can happen even with masters
 Incidence of PCR 0.05 - 10 %
 Incidence of Vitreous Loss 2 – 5 %

20.  At the time of hydro dissection
 Phacoemulsification
 Cortex removal by I / A
 During IOL insertion

21.  Gel like due to arrangement of long thin non
branching collagen fibrils suspended in a
network of glycosaminoglycan chains.
 Is attached densely to Ora serrata and is
loosely adherent to optic nerve and macula.
 Therefore Vitreous loss can lead to
complications like CME and RD.

22.  Vitreous is supposed to be in the posterior
segment so prevent vitreous traction
intraop and postop
 Maintain normotensive globe and leave a
clean anterior segment
 Protect cornea,iris,capsule from collateral
damage

23.  Total and safe removal of remaining lens material
 Preserve as much capsule as possible to place IOL
 Thorough removal of vitreous from wound and
anterior chamber

24. Use a dispersive and cohesive dispersive
viscoelastic to compartmentalize and
pressurize the globe
Convert rent to CCC
Raise nuclear fragments over the iris :
dial,lift,cantilever with nuclear spears
through sideport and trap with
viscoelasticuUse

25.  If PCR occurs, closed chamber system necessary.
 If remaining surgery managed without disturbing the
anterior hyaloid phase, then vitrectomy may not be
required.
 However, once anterior hyaloid is breached, then
vitrectomy necessary.

26.  Establishment of semi-closed pressurized
system necessary as chamber collapse will
promote forward movement of vitreous.
 Avoid burnt hand reflex – Phaco tip should not
be removed. Aspiration stopped immediately
after identification of PCR.
 Continue in position 1 ( irrigation ).
 Second instrument removed from side port and
Viscoelastic filled in AC.
 Then Phaco tip is removed from eye.

27.  Vitreous body similar to semi elastic material -
slinky toy
 If one pulls on the top few coils of the slinky, it
stretches but no tensions are exerted through out
the remaining toy.
 Similarly if amount of anterior vitreous disturbed is
limited, then tensions are not exerted throughout
the vitreous body, therefore CME and RD is
decreased.

28.  If one forcefully pulls on all coils of the slinky toy,
tension is exerted all the way down the toy.
 This is similar to extensive vitreous loss exerting
traction at vitreo-macular interface and vitreous
base causing CME and RD.
 So DO NOT STRETCH THE SLINKY.

30.  Force can rip open the posterior capsule
permitting more vitreous loss.
 Hydrates the vitreous causing forward
movement.
 Shakes and wiggles the vitreous causing forward
movement.

32.  Infusion and cutter should be divorced:biaxial
 Main Phaco incision should not be used.
 Eye filled with visco.
 New incision little right to Phaco incision for
vitrectomy tip (if only one side port).
 Left side port for infusion, right side for
vitrectomy.
 Phaco incision closes spontaneously.
 Therefore closed system vitrectomy.

35.  Infusion should be gentle and limited to AC
with Canula parallel to iris.
 Vitrector should be passed below the
posterior capsule at the point at which
minimal anterior vitrectomy should be done
and stopped when the vitreous is removed
below the level of posterior capsule.
 Advance towards vitreous while cutting and
anticipate repeat vitreous presentation
 Fill the eye with Visco, and insert three
piece foldable IOL on CCC

37. Triamcinolone acetonide binds to vitreous
Facilitates vit recognition and removal
Reduces postop inflammation
Use diluted 10:1
Use highest cut rate and vacuum of 200-300
for vitrectomy to minimize traction

38.  Instead of using original incision, a pars plana
vitrectomy with low suction, high cutting rate
can be done if surgeon well versed.
 23 G or 25G Trocar Cannula System of
Sutureless Vitrectomy has the advantage of fine
instruments and no sutures

39.  Alternative technique : Dry (no infusion)
vitrectomy – viscoelastic agent used
to maintain anterior segment while
vitrectomy performed through opening
in torn capsule.
 Cortex is best removed under viscoelastic
using Simcoe cannula

40.  Monitor IOP and treat
 Warn patient to expect floaters
 Detailed retinal examination
 Monitoring for CME
 DISCLOSURE TO PATIENT
 Antibiotic and NSAID and long taper of
steroid