EyeWorld Asia-Pacific September 2014 Issue

44 EWAP CAtArACt/IOL September 2014 Because a larger capsulorhexis allows the lens optic to come forward when the capsule contracts around the lens implant, the potential exists for a slight myopic shift. Conversely, a smaller capsulorhexis may result in fibrosis, and a capsulorhexis that overlaps the optic on one side and is outside the optic on the other may result in lens tilt that would lead to astigmatism once the wound has healed, she said. In theory, those variables are eliminated with the femto. “Having a well-centered, perfect, reproducible rhexis is an important safety aspect of the surgery that should not be overlooked,” Dr. Schallhorn said, especially for the less experienced surgeon. But “it will take many eyes to know whether or not there is a statistical difference,” Dr. Yoo said. “But in clinical practice, I’ve started to be more critical of my manual capsulorhexis.” Any part of the surgery that can help keep the IOL centered and planar “will keep results similar, making it easier to evaluate your own nomogram and make adjustments to the nomogram as necessary,” Dr. Trattler said. Additionally, lens fragmentation and cataract removal can be done atraumatically, he said, “so there’s less risk of any zonular injury or dehiscence that could lead to some slight decentration of the enscapsular bag complex.” Using the femto to create the entry wound may also have benefits, Dr. Schallhorn said. “A trilaminar wound is less likely to leak, and theoretically we’ll have more predictable surgically induced astigmatism,” he said. In the foreseeable future, Dr. Trattler expects 3D analysis of the entire anterior chamber including the capsular bag and zonular configuration, which will make it easier to predict the final effective lens position for IOLs. Clinical experience Dr. Kontos’ group is studying using the femto for cataract to correct lower levels of astigmatism, and “our preliminary numbers look really good. We’re making an impact on that group,” he said, and most patients report not needing spectacles postoperatively. The femto is already having a positive effect with complex cases, Dr. Yoo said. “Using the laser in pseudoexfoliation or weakened zonules with a very dense lens makes the case a little easier to manage,” she said. Dr. Trattler said fragmenting dense cataracts is much easier with the femto, too, and reduces the total amount of phaco energy, resulting in less corneal edema postop. Dr. Kontos prefers the laser to marking the cornea in cases of astigmatism. “When the laser makes the mark, we can line up exactly on that and it’s easy to verify we’re on the right spot, whereas there’s a bit more difficulty with manual marking. Whether or not our femto marks are correct is another story,” he said. Some surgeons are opting to use the laser regardless of payment “because of the patient dynamics,” Dr. Kontos said. “We’re doing it because it makes more sense clinically. It’s more likely to produce a good outcome in complex cases.” Next to improve? With the consistent capsulorhexis, “I think it will lead to different IOL designs,” Dr. Schallhorn said. “I predict we’ll see IOLs that are designed around the rhexis—we will know how the capsule will behave in any patient and that will allow us to design an IOL that takes advantage of that knowledge.” Dr. Kontos said the field is already evolving in terms of instrumentation that takes advantage of the femto’s qualities. “IOL development is a longer process,” he said. “The capsulotomy is going Can the femto - from page 42 to be the key for all future IOL designs, and it’s because of the femto,” Dr. Trattler said. “That ‘sweet spot’ we sometimes struggle to find isn’t as much of an issue with the femto.” Dr. Yoo said that some of the newer IOL designs (such as the bag- in-lens IOL developed by Marie- José Tassignon, MD) can already take advantage of the precise anterior capsulotomy. Patients will also drive the innovation, Dr. Kontos said. “With the laser, we’re now able to tighten our refractive results down to where cataract is almost as good as our LASIK outcomes. We’re finding we don’t have to fine-tune as often as we used to, and that will end up driving referrals.” EWAP Editors’ note: Drs. Kontos and Schallhorn have financial interests with Abbott Medical Optics (Santa Ana, Calif., U.S.). Dr. Trattler has financial interests with Abbott Medical Optics, LENSAR (Orlando, Fla., U.S.), Alcon (Fort Worth, Texas, U.S.), and Bausch + Lomb (Bridgewater, NJ, U.S.). Dr. Yoo has financial interests with Abbott Medical Optics, Alcon, and Bausch + Lomb. Contact information Kontos: mark.kontos@empireeye.com Schallhorn: scschallhorn@yahoo.com trattler: wtrattler@gmail.com Yoo: syoo@med.miami.edu