Update on Femtosecond Laser Cataract Surgery

Transcription

1 Update on Femtosecond Laser Cataract Surgery Eric Donnenfeld, M.D. Ophthalmic Consultants of Long Island and Connecticut Clinical Professor of Ophthalmology NYU Trustee Dartmouth Medical School ASCRS President I am a consultant for: Acufocus Allergan Alcon AMO Aquesys Bausch & Lomb CRST Elenza Glaukos Kala Lacripen Lensx Mati Pharmaceuticals Merck Disclosure Mimetogen Novabay Ocuhub Odyssey Pfizer PRN QLT RPS Sarcode Strathspey Crown Tearlab TearScience TLC Laser Centers TrueVision Wavetec Safety Endothelial cell loss Vitreous loss CME Endophthalmitis Retinal detachment Efficacy and Accuracy Distance Correction Predictability Biometry/Keratometry Astigmatism Correction Effective Power of IOL Effectiveness of Modern Cataract Surgery Common Incidence Vision Threatening Incidence Posterior Capsular Opacification 10 30% Retinal Detachment % Cystoid Macular Edema (transient) 2 10% Cystoid Macular Edema (persistent) 1 2% Vitreous Loss 1 5% IOL Malposition 0.3% Corneal Endothelial Cell Loss 4 10% Need for Corneal Transplant 0.3% Endophthalmitis 0.1% 1 Pereira et al. JCRS 2006 Oct;32(10): Park et al. Ophthalmic Surg Lasers Imaging Mar Apr;41(2): Apr;41(2): Femtosecond Cataract Growing Literature Published Papers on Lenticular or Cataract Surgery Applications for Femtosecond Lasers Surgical Systems Surgical Systems LenSx LensAR Catalys Victus 1

2 Femtosecond Laser Guided by 3 D Imaging Key to success is accurate real time imaging Image cornea, iris, lens Image Guidance Modalities by System LenSx (Alcon): OCT. Can visualize multiple views including Catalys (Abbott): 3D Full Volume OCT; Automated and side view, capsular bag; topographic view, lens; side view, user adjustable 3D surface identification and treatment cornea customization 500µm Safety Zone 500µm Image Guidance Modalities by System Simple template based software MK7935 Images are owned or licensed by Abbott Medical Optics Inc. Laser Cataract Surgery 4 Indications and Associated Clinical Benefits Capsulotomy up to 10x more precise Manual vs Femtosecond Capsulotomy Lens Fragmentation ability to soften lens, and reduce ultrasound energy Manual Capsulorhexis Laser Capsulotomy Arcuate Incisions for astigmatism correction more precise control, option for intrastromal incisions COMPARATIVE CLINICAL RESULTS Cataract Incisions 3D architecture for better sealability and reproducibility 2

3 Potential Implications of an Capsulotomy Precise capsulotomy with optimized location Improved The size, shape, and positioning of the capsulorhexis is a key determinant for effective lens position¹ Capsulorhexis Centration? Center over the dilated pupil? Center over the nondilated pupil? Center over the visual axis? More accurate & repeatable capsule healing Better IOL performance A 0.5mm Manual axial plane deviation from Laserintended ELP results in 1D of refractive error² Better visual outcomes 1Yanoff M, Duker J: Ophthalmology: Expert Consult 3 rd edition, Mosby, Manual Laser 2Cekic O, Batman C: The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers 1999, 30(3): OCT view Improved Architecture Cataract Incisions During Planning Side Cut Angle Range: Day 7 post-op op Challenges Limbal Relaxing Incisions Variable and unpredictable treatment and response Imprecise depth, length, angulation and position of incision LRIs are an art form not a science MK rev A Tighter self-sealing sealing sealing wounds and more consistent incisions Laser Refractive Cataract Surgery Arc Incisions Fully Customizable and adjustable Refractive incisions are no long an art form. They are a science. Place Desired dincisions: i EXACT Size EXACT Place EXACT Depth Challenges Limbal Relaxing Incisions The incisions may be a science but the response remains unpredictable Variable response in incision due to: Age Corneal ldiameter/curvature t Pachymetry Corneal biomechanics IOP LenSx Femtosecond Laser 3

4 Femtosecond Laser Arc Incisions are Adjustable Full effect of the incision is not achieved until the incision is manually opened Intraoperatively or postop Titrate t response to laser by adjusting Line separation Spot separation Energy Angulation of incision Starting Laser Nomogram Donnenfeld Nomogram for Limbal Relaxing Incisions Nomogram for 9 mm Arc Incisions 0.50 D 1 Incision, 1 ½ Clock Hours (45 Deg. Each) 1 Incision, 1 Clock Hours (30 Deg. Each) 0.75 D 2 Incisions, 1 Clock Hour (30 Deg. Each) 2 Incisions, 2/3 Clock Hour (20 Deg. Each) 1.50 D 2 Incisions, 2 Clock Hours (60 Deg. Each) 2 Incisions, 11/3 Clock Hours (40 Deg. Each) 3.00 D 2 Incision, 3 Clock Hours (90 Deg. Each) 2 Incision, 2Clock Hours (60 Deg. Each) *Use 5 degrees more for against the ruleastigmatism *Use 5 degrees more for younger patients *Use 5 degrees less for older patients 85% Depth Intrastromal Ablations for Astigmatism Less effective than full thickness incisions Smaller optical zones Bowman s membrane remains intact Less pain Reduced loss of corneal sensation Less dry eye Greater wound stability No need for antibiotics Conclusions LRIs and arcuate incisions are now playing an increasingly important role in refractive cataract surgery Manual llris can be performed din the office Femtosecond arcuate incisions may now be made at the time of cataract surgery with increased precision and safety Intrastromal arcuate incisions will play an important role in astigmatism management Ophthalmic Consultants of Long Island Laser Assisted Lens Fragmentation Increased ease of nucleus disassembly & phaco can lead to the following benefits: Reduction in phaco energy and time 1 Reduce corneal trauma and endothelial cell loss 1 Reduce risk of capsular tears Increase ability to use I/A alone 2 Faster visual recovery 2 46% reduction in phaco power 28% decrease in endothelial loss following laser cataract surgery vs. manual Reduced Phaco Energy and Endothelial Loss 1 Palanker D, Blumenkranz M, Andersen D, et al. Femtosecond laser-assisted assisted cataract surgery with integrated optical coherence tomography. Sci Transl Med ;2(58):58ra85. 2 Edwards KH, Frey RW,Naranjo-Tackman R, et al.clinical outcomes following laser cataract surgery. Invest Ophthalmol Vis Sci ;51:5394. Source: Knorz. Royal Hawaiian Eye Meeting Presentation, January

5 Lens fragmentation drives excellent outcomes Complete softening of the cataract that enables a fluidics driven lens removal,, providing a gentle procedure with minimal trauma to the eye Can segment and completely soften the nucleus with minimal gas generation Fragmentation volume maximized User adjustable grid spacing ( microns) Fast and easy cortical removal 1 Minimal corneal edema 2 and inflammation postoperatively 3 Segmentation Softening MK Jones et al. Proceedings from ASCRS Conrad Hengerer et al, JCRS Abell et al, JCRS These images are owned or licensed by Abbott Medical Optics Inc. seconds) EPT (s Optimized Grid Softening Reduces EPT 86% 500 µm grid LOCSIII: 3.5 ± µm grid LOCSIII: 3.7 ± 0.8 Complicated Eyes Advantages of Laser Cataract Surgery Dense nuclear cataracts Shallow anterior chambers Weak zonules Fuchs corneal dystrophy 0 n= 80 n= grid size (micrometers) Conrad-Hengerer et al, JCRS 2012; 38(11):

6 Sub Conjunctival Hemorrhage Complications More likely in older patients Suction pressure dependent Time dependent Vasoconstrictors may be helpful Pupil Constriction Maximal preop dilation Preop NSAID to help maintain dilation 10% Neo for poorly dilating pupils Avoid lasering capsule within 0.5 mm of iris Perform lens removal within 1 hour of femtosecond laser Intracameral epinephrine preservative free (1:5,000) if pupil constricts Incomplete Capsulotomy Newer software decreases this risk Evaluate CCC edge and use cystatome or forceps to confirm completion Do not hd hydrodissect di until confirmed complete or a radial tear may develop If incomplete, complete with forcep or cystatome Capsular Block Syndrome More likely due to: Perfectly round capsulotomy No specific point for fluid to escape Fluffed up cortex at capsulotomy edge blocks fluid egress Bubbles in capsular bag already creates intralenticular pressure Avoid excessive hydodissection Roberts T, Sutton G, Lawless M, Jindal-Bali S, Hodge C.Capsular block syndrome associated with femtosecond laser-assisted assisted cataract surgery.j Cataract Refract Surg. 2011;37(11): Conclusion Femtosecond Cataract Surgery Novel technology provides image guided laser cataract surgery. Computer controlled and laser accurate incisions Intrastromal incisions and self sealing wounds Precise capsulotomies which can be optimized for improved refractive results Reduced phacoemulsion time and energy New IOL designs will be coming 6