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Surgeon finds high rate of free-floating capsulotomies with femtosecond laser platform
In addition, irrigation and aspiration may not be more difficult after femtosecond laser treatment.
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The outcomes of cataract surgery have substantially improved with the evolution of equipment, technology and surgical techniques. The newest advance in this field is the use of femtosecond lasers to treat cataract. The femtosecond laser technology fires laser pulses at a much quicker speed than excimer and Nd:YAG lasers, eliminating heat generation and collateral damage. A femtosecond laser rhexis has improved circularity and centration, provides a more precise capsulotomy size and increases the possibility of greater architectural stability compared with manual rhexis. This can translate to better outcomes.
At this time, there are four femtosecond lasers systems for cataract procedures commercially available in the United States. They are Catalys (Abbott Medical Optics), LenSx (Alcon Laboratories), Lensar (Lensar) and Victus (Bausch + Lomb Technolas). The nuts and bolts of the systems are similar; however, they differ in their technology for imaging, docking and laser algorithms.
Some surgeons believe that capsulotomies made with the femtosecond laser produce fewer free-floating caps and more posterior “tear-outs” compared with manual techniques. Some early reports with certain femtosecond laser systems support that belief. Also, surgeons may be concerned about anecdotal reports that irrigation and aspiration can be more difficult after femtosecond laser treatment.
I believe it is incorrect to generalize and assume that all femtosecond laser systems produce the same architecture and rates of free-floating capsulotomies and capsular tags. All femtosecond laser systems are not created equal. Recently I have been using the Victus with a high rate of success.
Jeffrey Whitman
Details of the platform
The Victus has U.S. Food and Drug Administration clearance for both cataract and corneal procedures. It is indicated for use in the creation of a corneal flap in patients undergoing LASIK surgery or other treatments requiring initial lamellar resection of the cornea; for anterior capsulotomy during cataract surgery; and for the creation of penetrating arcuate cuts/incisions in the cornea in patients undergoing cataract surgery or other ophthalmic procedures. The system has a curved patient interface with real-time optical coherence tomography monitoring via multiple pressure sensors in three dimensions. The pressure is optimized to avoid corneal applanation and posterior corneal folds, which enables a precise and complete cut.
Retrospective review
Because my experience with the Victus has been different from that reported with other lasers, I decided to retrospectively evaluate the last 200 consecutive capsulotomies from my practice.
My review revealed that in my last 200 cases, 100% had free-floating caps. The laser produced a clean, precise cut, which may increase the capsule edge strength.
In anecdotal experience of four other surgeons and myself using the Victus laser platform for cataract procedures in 1,200 cases, there were no complications reported except one non-complete capsulorrhexis, which was attributed to patient movement. A common theme among these surgeons was the use of bimanual I&A to achieve optimal outcomes with femtosecond laser-assisted cataract surgery.
In regard to I&A, as with any new technique, I believe surgeons are a bit more timid. One technique that I find useful is to undermine the anterior capsule rim for 3 to 5 clock hours because the lens tends to push up toward the rim and can cause an unintentional seal. If this is not broken by undermining around the capsular rim, it is possible for sequestered gas and hydrodissection fluid to “blow out” the capsule because it has nowhere else to go. I then perform my normal hydrodissection and rotate the nucleus. Once I learned this technique, my cortical removal times became as fast as or faster than with a manual technique.
Reference:
Donaldson KE, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.09.002.For more information:
Jeffrey Whitman, MD, can be reached at Key-Whitman Eye Center, 2801 Lemmon Ave., Suite 400, Dallas, TX 75204; 214-754-000; email: whitman@keywhitman.com.Disclosure: Whitman is a consultant to Bausch + Lomb.