FEMTOSECOND LASER CATARACT SURGERY; IS IT REALLY SAFE? Ahmed Assaf, MD, PhD, FRCSEd, Prof. Ain Shams University Al-Watany Eye Hospital

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1 FEMTOSECOND LASER CATARACT SURGERY; IS IT REALLY SAFE? Ahmed Assaf, MD, PhD, FRCSEd, Prof. Ain Shams University Al-Watany Eye Hospital

2 NO FINANCIAL INTEREST Though, I wish to.. SALEH AL-MESSABI

3 FEMTOSECOND CATARACT SURGERY (FLACS) Approved in 2010 for: Capsulotomy Lens Fragmentation Corneal incisions Astigmatic kertotomies. FLACS LITERATURE Better self sealing incisions Less endothelial cell loss Less effective phaco time time Less postoperative inflammation More accurate reduction of astigmatism Better quality of vision Faster visual recovery Few complications

4 PEER REVIEWED PAPERS Lack randomisation Single-center No blinding. Risk of bias. RISK OF BIAS & FINANCIAL TIES

5 RISK OF BIAS & FINANCIAL TIES RISK OF BIAS & FINANCIAL TIES

6 FACTS COMPANIES ARE HIDING FROM YOU RHEXIS

7 FLACS CREATES PRISTINE RHEXIS More rubost More precise and consistent Better size, more circular better ELP of the IOL.

8 DECENTRATION & TILT WITH MANUAL PHACO Mean IOL decentration: 0.28mm ± 0.16 & tilt 2.61 ± 1.2

9 HOW MUCH DECENTRATION AND TILT CAN EFFECT VISION? Minimal effect of decentration and tilt on MTF (visual quality) WOULD LESS DECENTRATION & TILT PROVIDE BETTER VISION?

10 FLACS CREATES STRONGER RHEXIS Stronger than manual CCC Femto strength tests should evaluate strength of the capsule rather than the rhexis! Auffarth, Reddy, Ritter, Holzer, Rabsilber. Comparison of the maximum applicable stretch force after femtosecond laser assisted and manual anterior capsulotomy. J Cataract Refract Surg 2013; 39: Trikha, Turnbull, Morris, Anderson;3 and P Hossain1;The journey to femtosecond laser-assisted cataract surgery: new beginnings or a false dawn? Eye (2013) 27, ; doi: /eye ; published online 1 February 2013 FLACS CREATES SMOOTH RHEXIS AS MANUAL CCC Manual Femto

11 FLACS CREATES SMOOTH RHEXIS AS MANUAL CCC Manual Femto Femto Femto Femto Femto ANTERIOR CAPSULAR TAGS Capsulotomy is NOT 100% Anterior capsular tags (10.5%) New platforms minimized but did NOT eleminate it Anterior capsular tear (4%) Posterior extension (2%) Bali SJ, Hodge C, Lawless M, Roberts TV, Sutton G. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012; 119(5): Zoltan Z. Nagy, MD, DSc, Agnes I. Takacs, MD, Tamas Filkorn, MD, Kinga Kranitz, MD, Andrea Gyenes, MD, Eva Juhasz, MD, Gabor L. Sandor, MD, Illes Kovacs, MD, PhD, Tibor Juhasz, MD, PhD, Stephen Slade, MD. Complications of femtosecond laser assisted cataract surgery. J Cataract Refract Surg 2014; 40:20 28

12 ANTERIOR CAPSULAR TAGS Irregular laser delivery Corneal folds Corneal opacities Tilt Eye movement Bali SJ, Hodge C, Lawless M, Roberts TV, Sutton G. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012; 119(5): Zoltan Z. Nagy, MD, DSc, Agnes I. Takacs, MD, Tamas Filkorn, MD, Kinga Kranitz, MD, Andrea Gyenes, MD, Eva Juhasz, MD, Gabor L. Sandor, MD, Illes Kovacs, MD, PhD, Tibor Juhasz, MD, PhD, Stephen Slade, MD. Complications of femtosecond laser assisted cataract surgery. J Cataract Refract Surg 2014; 40:20 28 ANTERIOR CAPSULAR TAGS Dim red reflex because of lens fragmentation makes those tags difficult to indentify. Those tags cause some irregularities at the edge of the rhexis and can radialize into anterior capsular tear. This way we take an easy case and make it HARD!!! Bali SJ, Hodge C, Lawless M, Roberts TV, Sutton G. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012; 119(5): Zoltan Z. Nagy, MD, DSc, Agnes I. Takacs, MD, Tamas Filkorn, MD, Kinga Kranitz, MD, Andrea Gyenes, MD, Eva Juhasz, MD, Gabor L. Sandor, MD, Illes Kovacs, MD, PhD, Tibor Juhasz, MD, PhD, Stephen Slade, MD. Complications of femtosecond laser assisted cataract surgery. J Cataract Refract Surg 2014; 40:20 28

13 RHEXIS OVERTIME Kránitz K, Takacs A, Mihaltz K, Kovacs I, Knorz MC, Nagy ZZ. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011:1 6. CHEAPER WAYS TO CREAT GOOD RHEXIS

14 LENS FRAGMENTATION FLACS IS SAFE BECAUSE IT REDUCES EPT Technique was not specified in the manual group Reduction of ultrasound power by 43% compared to divide and conquer Trikha, Turnbull, Morris, Anderson;3 and P Hossain1;The journey to femtosecond laserassisted cataract surgery: new beginnings or a false dawn? Eye (2013) 27, ; doi: /eye ; published online 1 February 2013 Hengerer, MD, Schultz, Burkhard Dick, Effect of femtosecond laser fragmentation of the nucleus with different softening grid sizes on effective phaco time in cataract surgery. J Cataract Refract Surg 2012; 38: With manual phaco: significant reduction of EPT by phaco chop compared to divide and conquer

15 ENDOTHELIAL CELL LOSS ENDOTHELIAL CELL LOSS

16 CENTRAL CORNEAL THICKNESS IRRIGATING FLUID

17 EPT REDUCTION IS MANDATORY IN HARD CATARACTS Technique US technology OVDs! INCOMPLETE LENS CHOP Pre-chop may be necessary even in N+ cataracts!

18 CORNEAL INCISIONS FLACS CREATES BETTER SELF SEALING INCISIONS Retrospective study Compared age-matched groups Grade of cataract was not specified in each group Selection criteria for FLACS, difficult cases are excluded so direct comparison CAN NOT be made!

19 FLACS CREATES BETTER SELF SEALING INCISIONS Anterior Location Need to be opened by spatula Occasionaly by keratome! SIA? Peripheral corneal opacities (trachomatous pannus, arcus senilis) affects the quality of incisions and cause dispersion of laser energy. FLACS PRACTICALITIES AND LIMITATIONS

20 DOCKING Different age group. Different intellectual function Patient compliance. Poor mobility Tremor Inability to lie flat Deep set eyes Narrow palpebral apertures Limited patient mobility RETROLENTAL GAS May extend anterior capsular tag to tear May cause rupture of posterior capsule Hydrodissection!! Easy case difficult

21 PUPILLARY CONSTRICTION Femtosecond Lasers create shockwaves Hitting the pupil margin cause farther miosis FLACS & NARROW PUPIL

22 INCOMPLETE CAPSULOTOMY USING FLACS WITH A PUPIL EXPANSION DEVICE Dilraj S. Grewal, MD, Surendra Basti, MD. Incomplete capsulotomy using femtosecond laser with a pupil expansion device. JCRS VOL 40, APRIL 2014 OTHER LIMITATIONS Subconjunctival Hge Cortex removal Timing issues

23 TAKE HOME MESSAGE FLACS is rapidly evolving technology. We have purchased 2 femto platforms in our surgical facility New techniques, new complications, learning curve. IS IT AN ADDITION TO THE CURRENT PHACO TECHNOLOGY? May Be IS IT THE FUTURE TECHNOLOGY? IS IT SAFE? Yes No

24 AKNOWLEDGMENT to Ahmed Osama Hashem MD, MSc ARVO EGYPT November 2014, Submit your paper before August, 31

25 THANK YOU