Publication Exclusive: Correct technique, tools can optimize femtosecond surgery outcomes

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.

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.