EyeWorld Asia-Pacific June 2016 Issue

+VOe 2016 18 EWAP FEATURE 10 pearls for transitioning to femtosecond laser-assisted cataract surgery by Ellen Stodola EyeWorld Staff Writer N eda Shamie, MD , Los Angeles, presented her top 10 pearls for transitioning to femtosecond laser- assisted cataract surgery during a session at the 2016 Hawaiian Eye meeting. Pearl 1 is you need to know your tools. “You need to know the strengths and weaknesses of your tools,” she said. There are four femtosecond platforms available, and Dr. Shamie has operated on three of them. All of the platforms have “wonderful strengths,” she said. It’s helpful to have access to multiple laser platforms because this allows for customization of the procedure to different patients’ needs. Her second pearl was to expand preoperative considerations. When surgeons are performing cataract surgery in the traditional way, they may become confident that they’ll be able to deal with certain issues when they get to the operating room. “But with the laser, because we’re still in the learning phase, we need to think about this and anticipate problems a bit more,” she said. Scars can impede laser applications and can cause capsular problems. The grading of the density of the lens is important to do at the slit lamp. “That’s where you can get a better sense of what the lens density is and decide on the type of cut you’re hoping to perform,” she said. Pearl 3 was that operative planning is critical. “Set the right expectations,” Dr. Shamie said. The patient needs to know that you may have to convert to traditional phaco and that you may not be able to use the laser. The fourth pearl related to docking the laser. “The patient needs to be flat on the table,” she said. “There needs to be minimal tolerance for moving.” She said it’s important to ensure centration and that there is no lens tilt. Using images on the screen can help make sure the treatment zone has enough space to the capsule. Pearl 5 was that you’re “not married to those incisions,” Dr. Shamie said. One of the benefits is that if you don’t open the incision, it seals back down. Also, if the incision is placed too centrally, don’t operate through that incision, she said. Dr. Shamie’s sixth pearl was to assume there are capsular tags. The question is how fragile those tags are and how easily you can disrupt them. “Ensure a complete capsulotomy before removing the cap.” The next pearl was to first burp and then wave. Soften the chamber, Dr. Shamie said. “Air bubbles can get trapped behind the lens, so you don’t want to be too aggressive in hydrodissection,” she said. You want to get some of those air bubbles out. Pearl 8 was for easy cleavage but difficult capture. The laser cuts minimize the need for grooves and ease the splitting of the segments. “Cleavage is very easy, but it’s important to know that these are tight spaces,” Dr. Shamie added. Next, Dr. Shamie said that you “may need 2 hands to tackle the cortex.” Her final pearl was to consider delaying LRI management. EWAP Editors’ note: Dr. Shamie has financial interests with Abbott Medical Optics (Abbott Park, Illinois), Allergan (Dublin), Bausch + Lomb (Bridgewater, New Jersey), Shire (Lexington, Massachusetts), and Nicox (Sophia Antipolis, France). Contact information Shamie: nshamie@yahoo.com Views from Asia-Paci c CHEE Soon Phaik, MD Senior Consultant & Head of Department Singapore National Eye Centre 11 Third Hospital Avenue Singapore 168751 Tel. no. +65-6227-7255 Fax no. +65-6227-7290 chee.soon.phaik@singhealth.com.sg T he learning curve for femtosecond laser-assisted cataract surgery is short. In addition to mastering the use of the laser, the surgeon will need to adapt his/her surgical steps in order to optimize the outcome. My pearls are listed below: 1. Select your initial cases. The patient should be cooperative, have a straight forward cataract, big pupil, wide palpebral aperture, and a small nose. 2. Record the density of the nucleus and develop an algorithm for the nuclear fragmentation pattern based on the nuclear density. This provides a treatment protocol that the ophthalmic technician can follow. For LOCS 1 to 3 nuclear density, I use a hybrid pattern combining rings and segments. For LOCS 4 and above, I prefer a grid pattern or 16 segments. 3. Explain the procedure to the patient in the clinic and remind him again just before the surgery. Talking to the patient to maintain his head position throughout the procedure is helpful in achieving a level docking and complete capsulotomy. 4. It is very important to have an adequately dilated pupil so as to achieve the desired capsulotomy size. Prescribing mydriatics to be instilled before the patient arrives at the surgical center together with topical NSAIDs a day before surgery and repeating the NSAID immediately post laser help to achieve and maintain a well-dilated pupil during phacoemulsi cation. 5. During the learning phase, the surgeon may wish to differ creating laser incisions and astigmatic keratotomies to a later stage, since inappropriately placed incisions make surgery dif cult. 6. Examine for completeness of capsulotomy routinely before proceeding with hydrodissection. Capsule dyes may be helpful when visibility is challenged by gas formation and cortex spilling out. Pull centripetally on capsule tags, perform capsulorhexis on bridges and round off any dog ears where appropriate. 7. Perform hydrodissection with reduced fluid volume and injection speed, releasing entrapped gas where possible. Anterior capsule rips can occur if the bag is rapidly expanded. 8. During phacoemulsification, minimize troughing, Instead completely crack the nucleus at the equator and posteriorly. Reduce ultrasound energy and increase vacuum settings. 9. During removal of lens cortex, aspirate beyond the capsulotomy rim to avoid snagging the capsulotomy rim which may induce a rip-out. 10. To optimize work flow, treat two patients with femtolaser before proceeding with phacoemulsi cation and thereafter alternate so that one patient would be available for surgery at any time. Editors’ note: Dr. Chee is a consultant for Abbott Medical Optics (Abbott Park, Ill.), Alcon (Fort Worth, Texas), Allergan (Dublin), Bausch + Lomb (Bridgewater, NJ), and Carl Zeiss (Jena, Germany).