EyeWorld India March 2015 Issue

37 EWAP CATARACT/IOL March 2015 by Maxine Lipner EyeWorld Senior Contributing Writer Finessing femtosecond cataract complications All eyes on the laser T he femtosecond laser is making inroads into cataract surgery and has garnered a reputation for safety. Still, that does not mean practitioners will not face complications with the femtosecond approach. EyeWorld asked practitioners to talk about some of the issues they have come up against with femtosecond cataract surgery. Alice T. Epitropoulos, MD , clinical assistant professor, Wexner Medical Center, Ohio State University, has been doing femtosecond cataract surgery for the last year. “It provides surgeons with an exciting new option to potentially improve patient outcomes and safety,” Dr. Epitropoulos said. “But the technology brings with it a host of new financial and clinical challenges, and as with any new technology, there is a learning curve associated with femtosecond cataract surgery.” Winning at tag removal One issue is that an incomplete capsulotomy can be created, Dr. Epitropoulos said. “Fortunately, with software and hardware, the incidence has decreased,” she said, adding that incomplete capsulotomy used to be about 10% and is now less than 1% with the newer upgrades in the software and patient interfaces. Still, keeping this in mind, Dr. Epitropoulos urges practitioners to be attentive and not schedule patients if they have corneal scars. “Also, if there are folds in the endothelium, that can contribute to capsular tags,” she said. “It’s important to be aware of things that can cause those tags.” Because radial tears can sometimes be difficult to identify immediately after capsulotomy, Dr. Epitropoulos advises practitioners to be vigilant and sure that the capsule is entirely free of these before proceeding with phacoemulsification. Some patients are at a slightly higher risk of developing a capsular continued on page 38 tag or an incomplete capsulotomy, she said. “These might be patients who have a significant lens tilt or steep corneas such as keratoconus,” Dr. Epitropoulos said, adding that in such cases, folds may be induced on the cornea with applanation. Neda Shamie, MD , associate professor of ophthalmology, University of Southern California Eye Institute, Los Angeles, came across a case involving tags in one of her early attempts with the femtosecond laser. This was before improvements in the software, she stressed, and was a rare case that led to radialization. Tags can become an issue if they are unrecognized and the lens is under pressure, she explained. If the practitioner decompresses the anterior chamber, the tag can turn into a radial tear. “However, if it is recognized by the surgeon and handled in such a way where the tag is carefully broken without allowing it to radialize, it becomes a moot point,” Dr. Shamie said. “I think the key point is to recognize where there may be a tag and when there is, address it as though it’s an unfinished capsulotomy.” This means reverting to traditional techniques of creating a circumlinear capsulotomy using Utrata forceps and tearing through the tag, Dr. Shamie said. To avoid this, particularly in initial cases, carefully move through the steps of going around the capsulotomy and make sure that there is no tag left, she instructed. Relieving bubble trouble If there are air bubbles behind the lens, Dr. Shamie recommended toggling the lens one way and then the other to allow these to egress out of the capsular bag before hydrodissecting. Dr. Epitropoulos agreed that the air bubbles generated from the laser should be gently decompressed. “If we hydrodissect too aggressively, rapid hydrodissection can lead to posterior capsular rupture,” Dr. Epitropoulos said. Prior to hydrodissection, Dr. Epitropoulos uses an Akahoshi To allow air bubbles generated from the laser to egress, some practitioners use a prechopper to complete the laser fragmentation. Source: Alice T. Epitropoulos, MD