EyeWorld Asia-Pacific June 2014 Issue

19 June 2014 EWAP FEAturE landscape of cataract surgery over the last 30 years,” Dr. Culbertson said. “I think it will be the same with this.” Preop Non-clinically, Dr. Culbertson cited the expense of femtosecond lasers for cataract surgery as a major preoperative complication. “That’s the biggest complication because it’s complicated for your wallet. The second biggest complication is that it takes extra time. The medical complications are small,” he said. Clinically, the preop docking procedure can pose a challenge, Dr. Culbertson said. He said the problems begin when the eye is tilted. When attaching the eye to the laser, if the eye is off center, this can increase the chance of suction loss, resulting in incompletion of treatment. If the centering is 10 degrees off, the eye will not be properly centered for functional access to the laser, he said. Manual adjustments can assist, but do not always work in these instances. The best way to avoid this complication is to stop the laser and recenter the eye within the first few seconds of docking, he said. The laser should be coupled “concentrically to the limbus”. The LenSx SoftFit PI helps with tilted and decentered docks, rendering them an uncommon occurrence, Dr. Cionni said. Docking with the device is easy and quick, he said. “Occasionally, however, we will encounter a patient who is not as cooperative as desired [and] the docking is not perfectly centered or a small degree of tilt is found. Suction loss is extremely rare and indeed, a complication I haven’t seen in my last 1,000 cases,” Dr. Cionni said. “You will occasionally find a patient with such a large corneal diameter that the primary or secondary incision would end up more anterior than desired if made at the most peripheral extent available with the femtosecond laser,” he said. “In those instances, I have disabled the primary and/ or secondary incision and instead constructed those incisions manually.” In addition, the pupil must be dilated for proper capsulotomy segmentation, Dr. Culbertson said. Developing a protocol for the nurse to sign off that he or she administered dilating drops in time for correct dilation is important, he said. Patients who receive drops in adequate time but still do not have good pupil dilation might not be good candidates for laser treatment. Intraop A key intraoperative complication in femtosecond laser-assisted cataract surgery is incomplete anterior capsulotomy. Dr. Nagy said that he and his colleagues found that this was the most important complication in the use of the femtosecond laser for cataract surgery. “I suggested to follow the contour of the rhexis with the capsulotomy forceps meticulously to avoid anterior tears. It was a successful approach,” he said. Dr. Culbertson said patients moving during the capsulotomy could cause this complication. Time is vital. The Catalys machine makes the capsulotomy in 1.5 seconds. “You want to make sure the eye is stable in the capsulotomy, no matter the time it takes,” he said. “Believe it or not, some people can’t keep their eyes still for 1.5 seconds. Even though the eye is coupled to the laser, there’s still potential for a little movement. A little movement can make a big difference in making the capsulotomy.” He tells his patients that undergoing the capsulotomy is like having a chest X-ray: They should take a deep breath, hold their breath, and not move. While he has not had an incomplete capsulotomy in more than a year of using the Catalys, it could occur, so he always acts as though the capsulotomy is incomplete, he said. He uses the capsulotomy forceps to grasp it, then moves it in a curved way, as though performing a regular curvilinear manual capsulotomy. “I think the problem that people get into is that they don’t recognize it, and they start pulling the capsule half away and start to get a radial tear,” he said. “It can result in a wraparound capsulotomy, where the tear in the capsule goes from the anterior surface of the capsule all the way around to the posterior surface. Then you can lose lens material and have to do a vitrectomy, and it’s a mess.” For hydrodissection, Dr. Cionni said aggression is unnecessary. Surgeons should be aware of the gas that can expand the lens, he said. “I suggest injecting just enough fluid to begin to move some of the gaseous bubbles found behind the nucleus and no more,” he said. “Once the bubbles move, use the hydrodissection cannula to advance the bubble/ hydrodissection wave around the equator by rotating the nucleus from the opposite pole from where you injected [balanced salt solution] and at the same time push gently posteriorly.” Dr. Culbertson said that he depresses one corner to burp out the gas. For those patients who have corneal opacities, including patients who have undergone radial keratotomy, Dr. Cionni also suggests increasing the energy level in the capsulotomy to approximately 10 mJ. Postop Postoperative complications with femtosecond laser- assisted cataract surgery are not significantly different than with manual techniques—one of the main selling points of the devices, according to the experts who spoke to EyeWorld . Besides possible mild, temporary subconjunctival hemorrhage, Dr. Cionni said that he has not found many, if any, minor or significant postoperative complications. The main complications happen intraoperatively, Dr. Culbertson said. “There’s nothing that the laser has created by virtue of using the laser that shows itself postoperatively,” he said. “There’s nothing that it creates by itself, other than some of these anatomic issues … that are present intraoperatively; if you had a complete tear in the capsule, that can cause complications postoperatively, but that would happen whether it’s a laser or not that caused it.” “I can’t think of anything the laser does that causes complications postoperatively,” Dr. Culbertson said. said. EWAP Editors’ note: Dr. Cionni has financial interests with Alcon and WaveTec Vision (Aliso Viejo, Calif., U.S.). Dr. Culbertson has financial interests with Abbott Medical Optics. Dr. Nagy has financial interests with Alcon. Contact information Cionni: +1-801-266-2283 Culbertson: wculbertson@med.miami.edu Nagy: nagy.zoltan_zsolt@med.semmelweis-univ. Femtosecond - from page 15