December 24, 2015
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Femtosecond laser assists in complex cataract surgery case

The Catalys was used in a patient with hard cataracts, deep-set eyes and small palpebral fissures.

Cataract surgery is usually safe and relatively easy to perform, especially for the experienced eye surgeon. However, the degree of surgical difficulty when performing phacoemulsification often parallels the degree of cataract density that the surgeon faces.

Phacoemulsification can be challenging when dealing with a very hard, brunescent cataract with a decreased protective epinuclear-cortex between the hard nucleus and the fragile capsule. If the lens is relatively unstable with compromised zonules, it further adds to the surgical difficulty. The potential collateral damage in these more difficult phacoemulsification cases can affect the iris, cornea and/or corneal endothelium, which may compromise the postoperative results and result in an unhappy patient who may require further surgery such as endothelial keratoplasty, if the corneal endothelium fails to recover from the extended surgical trauma. The combination of a fragile capsule and a brunescent cataract with a paucity of protective cortex can potentially contribute to capsular-lenticular block during hydrodissection or even a dropped nucleus. Surgeons have continued to improve and modify their surgical technique to help carry out a safe phaco procedure in these difficult cases that may be considered more stressful.

Femtosecond cataract surgery is a welcome addition to the cataract surgery arena, especially when dealing with hard cataracts. It can decrease the complexity of cataract surgery and provide a safe surgical procedure with an optimal postoperative result and a happy patient.

In this column, Dr. Page describes a case of hard cataracts that is further complicated with deep-set eyes and very narrow palpebral fissures.

Thomas “TJ” John, MD
OSN Surgical Maneuvers Column

A patient sought out femtosecond treatment to address declining vision that was affecting her livelihood as a scientist who spends a significant amount of time looking through a microscope. In the left eye, she had lifetime best corrected visual acuity of 20/60. She presented with amblyopia, myopia, very small pupils and small palpebral fissures. As a child, the patient had strabismus surgery. Finally, she also had significant nuclear sclerosis with a LOCS III grade of 4 for nuclear color and nuclear opalescence in both eyes. After discussing surgical options, the patient elected to undergo femtosecond laser-assisted cataract surgery and be corrected for distance vision, with a preoperative refractive error of –4 D in the left eye and –6 D in the right eye.

The flange of the Liquid Optics interface is approximately 1.8 cm from the point of contact with the eye. This allows the interface to be set in a deeper orbit with a smaller palpebral fissure.

Image: Page TF

Treatment

The initial attempt to perform femtosecond surgery was not successful. It was difficult to engage the patient interface due to her very small palpebral fissure, and even though I was able to place the interface on the eye and achieve initial suction, I lost suction during imaging and analysis. I reapplied the interface and attempted several times, but we would always lose suction at a certain point. I attributed this to deep-set eyes, the very small palpebral fissure, and scarring of the conjunctiva around the limbus caused by the prior strabismus surgery. The patient declined changing the surgical plan to conventional surgery and requested another attempt at femtosecond surgery using a different machine.

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We rescheduled surgery on the Catalys (Abbott Medical Optics) using the 12-mm Liquid Optics interface (LOI) with conical design. I achieved immediate suction and was able to proceed throughout the case with a single docking attempt and without any loss of suction. The capsulotomy was successfully performed without any residual tags and left a free-floating cap (See video at Healio.com/OSN/video). The segmentation and fragmentation of the nucleus also proceeded without complication. After a quick-chop technique with the lens already fragmented by the laser and standard irrigation and aspiration, I inserted a Tecnis ZCT225 IOL (Abbott Medical Optics). The procedure was repeated in the right eye, with an almost identical set of circumstances, also with a single docking attempt and without complication.

The patient achieved near plano results in both eyes. The right eye received a +15.50 ZCT150 IOL (Abbott Medical Optics); at 1-month postop, UCVA was 20/25 with a refraction of –0.25 +0.50 × 170, which corrected her to 20/20. The amblyopic left eye received a 19.0 ZCT225 IOL; at 1-month postop, UCVA was 20/40 with BCVA of 20/30 plano +0.75 × 005. At day 90, her UCVA was 20/20 with a refraction of plano +0.25 × 160.

Conclusion

An educated medical professional did independent research and determined that femtosecond technology was the best option available to preserve her vision and livelihood. To address special anatomy and previous surgery, utilization of the small LOI of the Catalys allowed the possibility of successful femtosecond surgery and was the solution for this atypical set of circumstances. This is the smallest interface on the market and has a more conical shape. This allows it to get into smaller eyes or eyes that may be set further back into the orbit. In 100% of my cases performed using the Catalys, I have achieved tag-less, free-floating caps — a critical component in determining the success of femtosecond surgery. The safety profile of this laser, in my opinion, gives me complete confidence for complex and routine cases.

Disclosure: Page reports he is a surgical consultant for Alcon, Abbott Medical Optics and Bausch + Lomb. John reports no relevant financial disclosures.