Is it your preference to use femtosecond laser-assisted cataract surgery for dense cataracts?

Issue: October 10, 2018

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FLACS may be safer

Some surgeons question the need for and value of FLACS for the management of routine cataract cases. In my experience, this technology has demonstrated benefits in certain conditions such as those with denser cataracts, weak zonules or low endothelial counts.

Patients with dense nuclei often present significant clinical challenges throughout the procedure, from the capsulorrhexis to nuclear division and phacoemulsification.

In the majority of cases, an experienced cataract surgeon can perform a well-centered capsulorrhexis and remove the cataractous lens without difficulty. However, in circumstances in which there is poor visualization of the capsule, an intumescent hypermature cataract and increased intralenticular pressure, there tends to be a higher risk for radial tear-out and complications. With today’s femtosecond platforms, the capsulotomy is extremely reliable and a consistent part of the procedure, even in these challenging cases.

Furthermore, dense cataracts require a greater amount of ultrasound energy and fluid, increasing the risk for thermal injury, trauma, endothelial loss and edema. The femtosecond laser procedure is able to pre-soften and fragment the lens, which can potentially reduce the amount of ultrasound energy during phacoemulsification. After the femto portion of the procedure, it is important to follow best practices for a dense nucleus, taking extra care to recoat the endothelium with a dispersive viscoelastic, achieve good cleavage of the nuclear segments before emulsifying and minimize the amount of energy in the eye.

Although it is difficult to objectively compare phaco time and energy with FLACS and traditional surgery, less energy means less surgical trauma to surrounding tissue and potentially faster recovery.

In summary, FLACS can make phacoemulsification of dense nuclei safer and less stressful for the surgeon, potentially reducing the risk for complications. Further randomized studies are needed to prove these potential clinical benefits.

Alice T. Epitropoulos, MD, FACS, is an OSN Cataract Surgery Board Member. Disclosure: Epitropoulos reports no relevant financial disclosures.

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The miLOOP is ideal

For extremely dense nuclear cataracts, the femto-fragmentation of the laser, at its standard settings, is often ineffective at creating enough softening of the nucleus to facilitate easy removal. The laser settings can be adjusted, however, to be more effectual by decreasing spot size separation (horizontal and vertical) and increasing the energy to max. These setting adjustments, however, will increase the laser time, sometimes up to 3 to 4 minutes, and the patient needs to be prepared to lie still for that long. Additionally, the release of bubbles as a byproduct of the laser will be greater, and care should be taken during hydrodissection to not rupture the posterior capsule.

The miLOOP technology (Iantech) has been a great advancement for the management of these dense nuclear cataracts. The nitinol material in the snare form to slice through the nucleus can address the posterior leathery plate that is otherwise the main challenge to nuclear disassembly. With the miLOOP, I am able to effectively cut through the dense cataract to create manageable pieces that can then be phacoemulsified more easily. Care should be taken during the miLOOP placement to ensure the loop remains between the capsule and the cataract. The radial forces with the miLOOP disassembly point centrally and minimize undue stress on the zonules.

The combination of FLACS (at the higher energy settings) and the miLOOP is the ideal way to approach these dense cataracts that in the past we have had to convert to extracapsular removal.

Marjan Farid, MD, is an OSN Cornea/External Disease Board Member. Disclosure: Farid reports no relevant financial disclosures.