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Correct technique, tools can optimize femtosecond surgery outcomes
A surgeon explains how he ‘unzips’ the capsule during femtosecond-laser assisted cataract surgery.
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Modern-day cataract surgery requires lysis of most, if not all, corticocapsular adhesions toward the outer lens surface and freeing cortical-nuclear attachments in the interior of the cataractous lens. Hydrodissection is utilized to shear corticocapsular adhesions, while hydrodelineation breaks the epinuclear-nuclear adhesions. These surgical steps will facilitate in-the-bag nuclear rotation, thus assisting in lens division and removal by the technique of the surgeon’s choice. Further, such separation of the cortex from the lens capsule will simplify cortical cleanup and help preserve an intact posterior lens capsule for in-the-bag IOL placement. Incomplete lysis of corticocapsular adhesions can impede effective nuclear rotation and may result in possible zonular stretch and/or zonular lysis that can compromise the capsule-zonular complex.
With the application of femtosecond laser technology to cataract surgery, the capsulorrhexis has become more precise, accurate and reproducible, and there usually is a significant reduction of effective phacoemulsification time and mean phaco energy during laser-assisted lens fragmentation. However, with such precise laser capsulorrhexis and nuclear fragmentation, the usual hydrodissection techniques and cortical removal may be somewhat challenging due to possible laser-induced bubbles in the fluid path and enhanced corticocapsular adhesions and relative absence of cortical tails or strands that can be easily grasped and aspirated. Hence, there is a need for continued modifications in surgical techniques, which will further improve and assist in simplification of femtosecond laser-assisted cataract surgery.
In this column, Dr. Palydowycz describes his surgical technique of “unzipping” the capsule during femtosecond laser-assisted cataract surgery.
Thomas “TJ” John, MD
OSN Surgical Maneuvers Editor
Femtosecond laser technology offers a number of advantages over traditional cataract surgery, including less energy necessary for phacoemulsification and the ability to achieve superior circularity and position of the capsulotomy. The application to dense lenses is unquestionable, particularly with regard to intraocular manipulation, decreased total phaco time, and preserving the integrity of the eye structure and endothelium.
Elements of cataract surgery that remain the same in both femto-assisted and traditional procedures include the critical importance of complete hydrodissection, lens rotation and effective capsular cleanup. In my experience, with the application of a femtosecond treatment, a modification is necessary to ensure adequate hydrodissection, lens rotation and efficient capsular cleanup.
Figure 1. Incision opening.
Figure 2. Unzipping capsule.
Source: Palydowycz S
I first adopted femtosecond technology in August 2014 when I acquired the Victus femtosecond laser platform (Bausch + Lomb). I was excited by this new technology and its capabilities of performing excellent lenticular and corneal applications. Because the platform utilizes a unique patient interface, the quality of work inside the lens, as well as within the cornea, is without compromise. I have found a precise capsulotomy is achieved, and as a result, the cortex has a different appearance when compared with a manual capsulorrhexis. I found that the cortex adhered to the capsule, making the initial hydrodissection, as well as cortical removal, more challenging. To address this, I developed a technique I call “unzipping” the capsule.
Technique
After a femtosecond laser treatment, my first step is to open the corneal incisions. To open and dissect the wounds, I use the Palydowycz finger manipulator (Bausch + Lomb Storz Ophthalmic Instruments E0789). I developed this instrument, also referred to as the “Paly Wacker,” years ago and have used it extensively in traditional cataract surgery. Now, with femto-assisted procedures, I find it indispensable for my approach. After the wounds are dissected and capsulotomy removed, starting 180° away from the primary incision, I use the Paly Wacker to find and cleave, or “unzip,” the plane between the capsule and the adherent cortex. Its rounded tip alleviates concerns of causing capsular tears. Also, its angle makes it ergonomically comfortable for both right- and left-hand use.
I diligently insert the Paly Wacker as far as can be seen, until the area of the zonules. As I became more comfortable with this technique, I was confident with unzipping the capsule underneath the iris. To fulfill the unzipping, I manipulate the instrument within the plane 240° to 280°. I also navigate through the paracentesis to complete the remaining 100° subincisionally.
In addition to dissecting and unzipping, I use the Paly Wacker to gently rock the lens to release retrolenticular bubbles captured behind the lens. After a complete unzipping, I hydrodissect normally. I have not encountered an instance in which I could not freely rotate the lens using this technique.
In my experience, unzipping the capsule has assisted in making femtosecond cataract procedures efficient, reproducible and safe. My approach and instrument utilization have dramatically improved the ease of dissecting femto-created incisions and cortical cleanup. During irrigation and aspiration, using the CapsuleGuard I/A handpiece (Bausch + Lomb Storz Ophthalmic Instruments), the remaining cortex can be efficiently aspirated without compromising the capsule. Employing this technique may help enhance the potential of femto-assisted cataract surgery and improve outcomes for patients.
References:
Abell RG, et al. Clin Exp Ophthalmol. 2013;doi:10.1111/ceo.12025.Alió JL, et al. J Refract Surg. 2014;doi:10.3928/1081597X-20140516-01.
Conrad-Hengerer I, et al. J Refract Surg. 2012;doi:10.3928/1081597X-20121116-02.
Liu HH, et al. Int J Ophthalmol. 2015;doi:10.3980/j.issn.2222-3959.2015.02.36.
Nagy ZZ, et al. J Refract Surg. 2011;doi:10.3928/1081597X-20110607-01.
Vasavada AR, et al. Indian J Ophthalmol. 2008;doi:10.4103/0301-4738.39113.
For more information:
Severin Palydowycz, MD, FACS, can be reached at Orange Regional Medical Pavilion, 75 Crystal Run Road, Suite 120, Middletown, NY 10941; email: la@tristateeye.com. Edited by Thomas “TJ” John, MD, a clinical associate professor at Loyola University at Chicago and in private practice in Oak Brook, Tinley Park and Oak Lawn, Ill. He can be reached at tjcornea@gmail.com.Disclosures: Palydowycz and John report no relevant financial disclosures.