EyeWorld India March 2020 Issue

CATARACT EWAP MARCH 2020 31 S pecific patient situations and evolving views on technology are informing surgeons’ approaches to capsulotomy creation, a procedure that can be performed manually or with various devices. Manual, femto, and Zepto Uday Devgan, MD, performs manual capsulorhexis, Zepto (Mynosys Cellular Devices) capsulotomies, and femtosecond laser capsulotomies, with his approach depending on the type of patient and their anatomy. “A routine case may not benefit from a Zepto or femto- laser capsulotomy as much as an intumescent, white cataract case,” Dr. Devgan explained. “Even then, there is no guarantee of success and you can have an incomplete laser-made capsulorhexis in some cases.” Surgeon skill is more influential on high-quality clinical outcomes, than use of technology like a femtosecond laser, Dr. Devgan said. For example, forceps can be used to create a 5-mm capsulorhexis, even if the pupil only dilates to 4 mm by passing the forceps tips under the iris— an approach is not possible with a femtosecond laser. In contrast, novice surgeons or those who have difficulty making an excellent capsulorhexis may improve their results by using a femtosecond laser or Zepto device, Dr. Devgan said. Larry Patterson, MD, performed femtosecond capsulotomies for 4 years and then about 2.5 years ago switched back to creating a manual capsulorhexis. Despite the expectation that femto-laser capsulotomies would increase accuracy and precision, Dr. Patterson found they weren’t as strong as those created manually. His return to manual was reinforced by studies repeatedly finding femtosecond-created capsulotomies were more likely to tear under pressure. “It wasn’t just the studies showing that, we were obviously getting more anterior capsular tears with the laser. I rarely have an anterior capsular tear now that we’ve switched back to 100% manual,” Dr. Patterson said. He also found femtosecond laser-created capsulotomies did not always end up exactly where he thought they would. “I can do a manual capsulotomy and I can put it exactly where I want it to be,” Dr. Patterson said. The additional cost and time added to the procedure were cited by the doctors as a disadvantage for using femtosecond lasers to create capsulotomies. But among newer devices that cost less than femtosecond laser systems is the Zepto capsulotomy system. Zepto uses a handpiece attached to a laptop-sized console to create a “phase transition” of water molecules trapped between the device and the capsule to create capsulotomies. Dr. Patterson said one advantage of this device is that it is performed on the operating table, which keeps operating time short. In addition, some reports indicate that it results in a stronger capsule edge. “There may be some other advantages, but for right now those all cost extra money and you can’t bill for the extra cost, so for the near future, we’ll be sticking with manual capsulotomies,” Dr. Patterson said. Creating the ideal capsulotomy For all planar, fixed-position Capsulotomy creation: Searching for perfection by Rich Daly EyeWorld Contributing Writer Contact information Devgan: devgan@gmail.com Patterson: larryp@ecotn.com Measurement is key to obtain an ideal capsulorhexis. This image demonstrates forceps which have built-in measurement capabilities for that purpose. This article originally appeared in the November 2019 issue of EyeWorld . It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.