Breakthrough femtosecond technology moves cataract surgery toward ‘photoemulsification’
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A new ultrafast femtosecond laser with a robotic arm and a novel disruptive technology for nucleus fragmentation is moving cataract surgery to the stage of all-laser “photoemulsification” surgery.
“Femtosecond lasers have been around for several years and have penetrated into the daily practice of eye surgeons. However, the majority of cataract surgeries are still not femto, and the proportion of FLACS is not increasing,” Pavel Stodulka, MD, PhD, said in an interview with Ocular Surgery News.
The femtolaser, he said, is still too complex and expensive, and it slows down the procedure in most cases.
Technology, however, never stops evolving, and a French company, Keranova, has introduced breakthrough innovations in this landscape.
“The first new feature of the Keranova femtomatrix laser is a robotic arm, which automates the first part of the surgery, the docking of the patient. The other femtosecond lasers, with the exception of the Ziemer Femto LDV, don’t have a movable arm, and you have to move the entire patient on a bed toward the laser until the patient’s eye gets in contact with the docking cone. In this new laser, the robotic arm travels to the eye of the patient,” Stodulka said.
Source: Pavel Stodulka, MD, PhD
This technology is still a work in progress, and manufacturers are developing an intelligent system, in which the robotic arm detects the eye and docks autoatically with ultra-precise image-guided robotic movements. Currently, the arm comes close to the patient’s eye, and the final stage of docking is performed by hand.
However, already at this stage the robotic arm simplifies the docking procedure and moves away at the end of the femtosecond-assisted part of surgery. The following intraocular part of the procedure is carried out in the same place, with no need to move the patient. The surgeon performs the intraocular maneuvers without wheeling the patient out to the operating microscope.
“This is safe, comfortable and convenient for both the patient and the surgeon,” Stodulka said.
Ultrafast fragmentation, no bubbles
A second and even more important innovation is the proprietary matrix technology. While a traditional laser makes incisions line by line, the Keranova laser generates multiple spots on the laser’s focal plane, distributed according to a configurable matrix. This is obtained by using a computer-controlled algorithm that modifies the wavefront of the laser beam.
“The laser spot is multiplied, resulting in 20 times the cutting speed of any other laser. The human lens is fragmented into 20,000 small cubes with a 0.2 mm side in 20 seconds, a very thorough fragmentation, and those little cubes can, in most of the cases, be aspirated with no need for ultrasound,” Stodulka said.
The energy required for fragmentation is modulated and customized by the smart software with the threshold scanning system of the laser to adapt not only to the hardness grade of each lens, but to different degrees of hardness within each lens.
“At the beginning of the procedure, the laser sends sampling laser beams into different parts of the lens and calculates for each part the exact amount of energy needed for fragmentation. These data are used to create a customized pattern for fragmentation,” Stodulka said.
This energy-sparing system allows for lens fragmentation with minimal or no formation of cavitation bubbles.
“Bubbles can interfere with fragmentation and block the laser. With the Keranova laser, you typically see no bubbles at all,” he said.
Nearing full automation
Stodulka performed the world’s first surgeries with this laser and is now conducting the CE mark study. He operated on 27 eyes, and in 25 of them, with cataract grade 1 to 5, lens emulsification was achieved without any ultrasound.
“We are getting close to full automation of the procedure, to photoemulsification, the new frontier of cataract surgery. Currently, about 80% of the cataract procedure can be performed safely and efficiently by the machine, while the surgeon’s hands are required only for aspiration and IOL implantation,” he said.
He expects that the Keranova femtomatrix laser will also have applications in refractive and corneal surgery. – by Michela Cimberle
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- Pavel Stodulka, MD, PhD, is director and chief surgeon at Gemini Eye Clinics in Zlin and Prague, Czech Republic, and Vienna, Austria. He can be reached at email: stodulka@lasik.cz.
Disclosure: Stodulka reports he is a paid investigator for Keranova.
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