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Femtosecond laser cataract system allows for broader inclusion criteria, surgeon says
Complicated cases can be safely managed thanks to the higher precision of laser surgery and the reduced use of ultrasound.
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MILAN, Italy — A femtosecond laser system enables fewer exclusion criteria for cataract surgery and a rapid increase in patient volume, according to one surgeon.
“We acquired the laser in December 2011, and we’ve had at least 100 patients per month asking to be treated with the new procedure. We have treated to date more than 560 cases,” H. Burkhard Dick, MD, OSN Europe Edition Associate Editor, said at the annual joint meeting of OSN and the Italian Society of Ophthalmology.
The Catalys Precision Laser System (OptiMedica) enables treatment when there are risk factors or exclusion criteria for conventional phacoemulsification, Prof. Dick said. Conjunctival alterations, opacified corneas, loose zonules, small non-dilating pupils, intraoperative floppy iris syndrome and pseudoexfoliation syndrome are no longer limitations to laser-assisted cataract surgery.
H. Burkhard Dick
The system allows for all-comer cataract surgery, Prof. Dick said, and he has not set any exclusion criteria thus far. Looking back at the first 400 patients treated at his clinic, he observed that there were many complicated cases, including 22 mature cataracts, 25 small pupils, 20 patients with glaucoma, 31 with pseudoexfoliation syndrome and 28 with corneal guttata.
“Usually I would have to exclude many of these eyes. My personal opinion is, the currently regarded contraindications and limitations … are for me the indications for laser cataract surgery,” he said.
Enhanced precision, safety
Optimizing the steps of the procedure according to key features of the laser enables broad inclusion criteria and the treatment of complex cases, Prof. Dick said.
The Catalys system’s Liquid Optics interface provides stable but gentle docking with minimal IOP increase.
“In a study of 100 patients, we measured IOP at various time points during laser surgery and saw that the peak increase was only 10 mm Hg. At the end of the procedure, IOP went back to preoperative measurements,” Prof. Dick said.
The Liquid Optics interface enables the surgeon to perform the procedure in small eyes as well.
Another key feature is the Integral Guidance, an OCT-guided mapping system that allows surgeons to customize treatment plans according to each patient’s ocular anatomy.
Both of these features enhance precision and safety in the performance of capsulotomy, whether anterior or posterior.
“We compared the deviation from target-size capsulotomy, which was set at 5 mm, in our first 400 laser cataract patients and in a similar number of manual cataract procedures. We found a deviation of 25 µm with femto compared to 345 µm in manual cataract surgery,” Prof. Dick said.
Free-floating capsulotomy was obtained in 99% of patients.
Methods, complications
In non-dilating small pupils (35 of 400 patients), epinephrine, viscomydriasis or implantation of a Malyugin ring was used.
“The non-applanating Liquid Optics interface facilitated small pupil management with no intra- or postoperative complications,” Prof. Dick said.
Laser fragmentation of the lens reduced phaco time by 96% compared to manual cataract surgery.
“Reducing the laser grid size for lens softening from 500 µm to 350 µm further decreased phaco time by an additional 86%,” he said.
Surgery with minimal ultrasound use enabled the inclusion of patients with Fuchs’ dystrophy and corneal guttata.
The overall complication rate was low, Prof. Dick said. There were two cases of anterior capsule tear, one of which extended to the posterior capsule, but there was no vitreous loss and the IOL was implanted in the capsular bag.
Following a protocol approved by an ethics committee, Prof. Dick also treated pediatric patients.
“The laser parameters were modified to perform posterior capsulotomy, reintroducing the same parameters used anteriorly,” he said. “This challenging step of pediatric cataract surgery is made easier and safer. I believe that femtosecond laser cataract will be the future in pediatrics.”
While the costs of femtosecond laser-assisted cataract surgery are often cited as a potential obstacle to widespread adoption of the technique, Prof. Dick said that in his experience, patients are prepared to pay for femtosecond laser treatment out of pocket.
“Patients have great faith in the magic of laser,” he said. “If they have budget limitations and I ask them whether they’d prefer a standard procedure with implantation of a premium lens or a femto procedure with implantation of a standard monofocal lens, they opt for the femto.” – by Michela Cimberle