EyeWorld Asia-Pacific December 2015 Issue

38 EWAP CATARACT/IOL December 2015 by Lauren Lipuma EyeWorld Staff Writer How has the femtosecond laser changed your cataract surgical technique? continued on page 45 Three surgeons share how their technique has changed since incorporating the laser into practice W hether for correcting astigmatism, removing the nucleus, or optimizing surgical efficiency, surgeons have to adopt a slightly different technique for femtosecond laser-assisted cataract surgery than for manual phaco. Most surgeons agree that there is a learning curve for the first 100 or so cases, and for physicians just starting out with this procedure, it can be helpful to know what unexpected issues may come up during surgery. EyeWorld asked laser cataract surgery pioneers Robert J. Cionni, MD , medical director, The Eye Institute of Utah, Salt Lake City; Zoltan Nagy, MD , clinical professor of ophthalmology, Semmelweis University, Budapest, Hungary; and Jonathan Talamo, MD , director, Massachusetts Eye and Ear Infirmary Waltham, Waltham, Mass., how their technique has changed since incorporating the laser into practice. Here, in their own words, Drs. Cionni, Nagy, and Talamo describe what makes laser cataract surgery different from manual. short, so the surgeon should check all steps before starting the laser pedal. The second most important thing to do for those who start with this technology is to follow the contour of the capsulotomy to avoid anterior tears. The next important step is the gentle hydrodissection to allow the intralenticular gas bubble to leave the eye through the anterior chamber without causing rupture of the posterior capsule. During hydrodissection, the lens should be moved up and down and must be rotated. This is the so-called “rock and roll” technique. With this method, I never had any rupture of the posterior capsule. A special chopper is needed to fragment the crystalline lens, and from then on, the procedure is similar to manual phacoemulsification. During laser cataract surgery, a larger epinucleus may stay, which has a protective role for the posterior capsule. During irrigation/aspiration (I/A), the surgeon should control this. Jonathan Talamo, MD Because you already have a cut in the anterior capsule, you have to be very careful not to destabilize the chamber when you enter the eye. In the unlikely event you have a residual attachment between the capsular disc and the peripheral capsule, if you put uncontrolled tension on that area, you could have a tear in the capsule. So I’ll enter very carefully and inflate with viscoelastic to minimize any chamber instability. Then I’ll proceed with what’s called a dimple-down maneuver, where I’ll use a cystotome, or more typically Utrata forceps, to remove the capsule; I will push down on the middle of the capsular disc to identify any tension striae where there may be adhesions. Once I’m certain that there are no adhesions, I’ll proceed with removal of the capsular disc. I tend not to inflate the anterior chamber as much as I otherwise would because when I go to hydrodissect, I want room for gas bubbles to come forward around the lens. If it seems that the gas generation from treating the lens has remained trapped in the capsular bag and the capsular bag is under tension, I enter the eye with my phaco probe and a second instrument and carefully push apart the cut segments of the lens to allow the gas bubbles to come forward and decompress the bag before I do further manipulation to free the nucleus. Instead of requiring hydrodissection with balanced salt solution, sometimes there’s either no or very little hydrodissection required. I will assess this situation before I proceed with the full hydrodissection by rocking the lens back and forth and seeing if it rotates freely. Robert J. Cionni, MD Since the lens is already fragmented, I rarely need to utilize a second intraocular instrument for lens manipulation. The improved fluidics of the Centurion Vision System (Alcon, Fort Worth, Texas) result in a more efficient procedure with less cumulative dissipated energy (CDE) and less fluid moved through the eye, typically around 20 cc instead of the 50–100 cc we saw before. Since we are not putting instruments in and out of the side port incision, this incision seals much more easily as well. The corneal arcuate incisions are much more precise with a more predictable effect than any manual incision I’ve ever made. I prefer to limit cylinder reduction with arcuate incisions to 2 D or less, using a toric IOL for more significant astigmatism management. Zoltan Nagy, MD The surgeon must have a plan before entering the OR. Therefore, I see every patient in the morning before surgery and I decide what to do. Laser pretreatment is very