Femtosecond laser assisted cataract surgery for cataract and rle. Prof.Dr.Mahmut Kaşkaloğlu Kaşkaloğlu Eye Hospital Izmir, Turkey

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1 Femtosecond laser assisted cataract surgery for cataract and rle Prof.Dr.Mahmut Kaşkaloğlu Kaşkaloğlu Eye Hospital Izmir, Turkey june 2016

2 No financial disclosure

3 Cataract surgery decreases mortality rate..united States Medicare patients with cataract, those who underwent cataract surgery had 30% reduced mortality compared with those who did not undergo surgery. Tseng VL,Yu F, PhD,1,3 Lum F, Coleman AL., Cataract Surgery and Mortality in the United States Medicare Population.Ophthalmology 2016;123:

4 Cataract surgery is the most common operation Europe average 10,000 per million 450,000 cataract operations in Turkey About 6000 per million Today many RLE with multifocals All patients expect perfect results How do we make it better and safer?

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6 ARC Laser's Dodick Laser Photolysis Nd:YAG Paradigm Photon Nd:YAG Asclepion-Meditec Phacolase Er:YAG WaveLight Adagio Er:YAG erbium:yag laser, Nd:YAG laser (2000)

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8 Femtosecond laser 1053nm(near IR) spectrum Focus 3µm Spot size Ultrashort pulse10-15 sec a Millionth of a Billionth of a sec No collateral damage Laser Energy is absorbed by tissue, causing plasma formation and molecules expand resulting cavitation bubbles and tissue separation

9 Femtolaser in ophthalmology: Flap creation: LASIK Lenticule extraction: SMILE Channel for ICR Corneal graft Intracor Arcuate incisions Glaucoma Cataract

10 Future use of Femtolaser in ophthalmology: Treatment of tractional vitreous attachments. Reversing presbyopia. Refractive index shaping. Corneal collagen crosslinking (CXL). Reversing cataract. Lubatschowski H. Applications of the Femtosecond Laser A new era of ophthalmology. CRST Europe 2012 feb

11 Problems with conventional phaco Difficult learning curve Dependent of the surgeon s dexterity For perfect results all steps must be within acceptable tolerances Most complications caused by the surgeon, 10X LASIK Many manual steps which cannot be executed with reproducible precision and predictability.

12 Potential benefits of Femto cataract surgery Efficacy : More predictable and accurate capsulotomy More consistent corneal incision construction Better refractive results Safety : Less ultrasound energy Less risk of capsule tears Less incision leakage and astigmatism

13 Current FS platforms LenSx (Alcon Lab., USA) Catalys (Optimedica Corp.,USA) LensAr (LensAr Inc., USA) Victus (Technolas, Germany; Bausch&Lomb, USA) Ziemer Femto LDV Z (Ziemer Ophthalmic System AG,USA)

14 Interface 1.Catalys: Liquid optics, nonapplanating 2.LensAR: Fluid interface, nonapplanating 3.LenSx: Curved lens, applanating 4.Victus: Dual modality 5.Ziemer: Liquid interface

15 Imaging 1.Catalys: 3D OCT 2.LensAR: Confocal Structured Illumination (3D-CSI) 3.LenSx: 3D OCT 4.Victus: 3D OCT 5.Ziemer: OCT

16 LenSx Laser Touch screen Graphic User Interface Real-time video imaging for 3D visualization True image-guided surgical planning Sterile or unsterile. Can be located in the same room or different rooms.

17 Applications of LenSx Corneal incisions Capsulotomy Laser lens fragmentation Arcuate incisions Lasik flaps (not yet available)

18 Patient selection General Can lie flat and still Back problems Tremor Inform Subconjunctival hemorrhage Check Lids Pupil dilation Anterior capsule Cataract type Zonules

19 Docking Patient lies flat to PI Bubbles in interface or suction loss: Undock and dock again Suction loss during femto: proceed with manual phaco

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22 Less induced astigmatism Trapezoid incision Stepped incision Self sealing Less wound leak Arcuate incisions Excellent reproducibility Corneal incisions Masket S, et al. Femtosecond laser-assisted cataract incisions: architectural stability and reproducibility. J Cataract Refract Surg. 2010

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24 Capsulotomy Exact sizing Stability Better Effective lens position Less capsular opacity Stable refraction Perfect shape Perfect centralization Less aberration Less phimoses More capsule strenght Less capsule tear 1. Nagy Z, et al. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg Kranitz K, et al. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorhexis parameters and their effects on intraocular lens centration. J Refract Surg Friedman NJ, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg Dick HB, et al. Intraocular lens fixated in the anterior capsulotomy created in the line of sight by a femtosecond laser. J Refract Surg. 2014

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26 CCC Manual CCC Laser CCC Deviation Diameter: 337± 258 µm Circle: %20 Deviation Diameter: 29 ± 26 µm Circle: % 6 Friedman NJ, et al. Femtosecond laser capsulotomy J Cataract Refract Surg, 2011.

27 Pupil size Optimal CCC for IOL: 4.8mm to 5.2mm Prefemto Pupil diameter 1.5mm larger than CCC To Prevent Pupil constriction after femto: Preop NSAI, Cyclopentolate, Neosynephrine Keep interval between femto and phaco short Repeat Neonynephrine after Femto Adrenaline in BSS First cases 40% now less than 15%

28 Watch for Intumescence Calcification Always stain capsule

29 Small Pupil Prefemto: Iris hooks or Malyugin ring Benefit to patient questionable If pupil too small for minimal CCC, manual phaco maybe safer Post femto: Adrenaline Viscodilation Iris hooks Malyugin ring What to do if you cannot do femto?

30 Hydrodissection Gently tap and tilt the nucleus Decompress air bubbles from behind the lens Gently inject BSS See bubbles come forward Aggressive, rapid, hydrodissection may cause posterior capsule rupture

31 Phacoemulsification o Divide&conquer, chop o Don t be discouraged during the learning curve o Our total femto procedure duration is now 10m vs 19m during the early period

32 Harder cataracts cylinder pattern facilitate central debulking

33 Matrix pattern

34 Lens fragmentation Effective phaco time (EPT) and cumulative dispersive energy (CDE) reduced 1,5 Central corneal thickness reduced, less endothelial cell loss 6 Some studies indicate less early macular thickness after Femto. 5. Conrad-Hengerer I, et al. Effect of femtosecond laser fragmentation on effective phacoemulsification time in cataract surgery. J Refract Surg Takacs AI, et al. Central corneal volume and endothelial cell count following femtosec-ond laser-assisted refractive cataract surgery compared to conventional phacoemulsification. J Refract Surg. 2012

35 Cortex removal During Femto CCC laser cuts 300µm circular cortex This is flush with the CCC edge Hydrodissection may not be possible between the capsule and the layer of cortex In theory this is a safety zone With some experience this is not an issue and all cortex can be removed easily

36 Arcuate Relaxing incisions: 80% depth Opened during surgery Opened later Nomograms are being developed Long term efficacy to be determined For refractive cataract and RLE cases toric IOL is the better option

37 RK+ RLE (FEMTO-AK) Preop. Data: - CDVA: 0.5/0.5 - Otoref.: - OD: x175 - OS: x110 - Corneal ast.: - OD 4.75 D - OS: 5.25 D - OD: Femto RLE+ mono toric - OS: Femto RLE+ mono toric+ AK Postop. Data: - UDVA: / Otoref.: OD: x90 OS: x115

38 Asena BS, Kaskaloglu M. Laser-assisted cataract surgery: softlens assisted interface(softfit) versus direct contact interface. Eur J Ophthalmol 2016; 26(3):

39 Kaskaloglu Eye Hospital Izmir February 2013-February eyes No laser complications Incomplete CCC in 62 eyes 1 anterior capsule tear 1 posterior capsule break Average operation time 14 minutes

40 Conclusion: We are still in the early phase of this advanced technology We already know that It can do CCC better than us May lead to better refractive outcome It can lower the phaco time May reduce endothelial cell loss Planned incision architecture Less induced astigmatism

41 Disadvantages: Narrow palpebral aperture, deep orbit, high brow Posture problems Corneal opacities Small pupil, synechia White, advanced cataract

42 Femto laser is a tool We will learn how to maximize this tool for the benefit of our patients. Change laser parameters such energy levels, spot separation for the type of cataract Manipulation will improve Remember how Nagahara chop and modifications revolutionized phaco

43 The Industry will improve the machine Interface Automatic recognition of the density of the cataract Improve automatic warnings to prevent Excess energy Wrong positioning Hopefully lower the cost

44 Many still are skeptical of the value of femto laser cataract surgery but it is here to stay for some time ICCE ICCE PHACO FEMTO?????

45 Thank you for your attention