femtosecond laser assistedcataractsurgery
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TRANSCRIPT
LASER-ASSISTED CATARACT SURGERY: THE FUTURE IS NOW
Alan Solinsky, MDDavid Jeng, MD
1013 Farmington AveWest Hartford, CT 06107
(860) [email protected]
Course Description
This course provides an overview of how femtosecond lasers can and will benefit
patients with cataracts and astigmatism.
Learning Objectives
To understand the uses of the femtosecond laser
To review the features of various systems and specifically the Alcon LenSx® Laser
To review the evidence in support of the functionality of femtosecond lasers
To recognize the benefit of the femtosecond laser in cataract surgery
Commercial Disclosures
Neither Alan Solinsky nor David Jeng has direct financial or proprietary interest in any of the companies or services mentioned in this presentation
Neither Alan Solinsky nor David Jeng has received commercial support from any of the mentioned companies
Alan Solinsky is affiliated with Allergan as a speaker.
The content and format of this course may reflect commercial bias BUT it does not claim superiority of any commercial product or service
Changing Face of Cataract Patients
Earlier diagnosis and treatment before substantial vision loss
Baby Boomer patients demanding high quality post-operative vision
New surgical approaches and lens implants available to improve UCVA for many patients
Premium Intraocular Lenses
Need for Improved Outcomes
What is a femtosecond laser?
A laser that emits optical pulses with a duration in the range of femtoseconds (1 fs = 10-15 seconds)
Allows for precise cutting of tissue with minimal collateral damage
Utilized since 2001 in ophthalmologic procedures such as LASIK, corneal transplants
Commercially Available Systems
Alcon LenSx® (approved for all steps) LensAR® system (approved for all steps) OptiMedica Catalys® (approved for all
steps) B+L Victus® (approved for corneal
flaps, incisions and anterior capsulotomy) AMO Intralase® FS (used in LASIK
flaps, approved for arcuate incisions only)
Commercially Available Systems
OptiMedica Catalys
Catalys
Liquid Optics™ Interface Integral Guidance™ Attached ergonomic surgical chair
LensAR
LensAR
Augmented Reality™ Optical ray-tracing (Schleimpflug imaging) Lens Tilt detection
Small footprint and Articulating arm may allow for positioning in one operating room
B+L Victus
Victus
Allows for LASIK flap creation and corneal incisions
Alcon LenSx
The LenSx® Laser was the first femtosecond laser cleared by the FDA for use in cataract surgery. It is indicated for: Anterior capsulotomy Lens fragmentation All corneal incisions
The LenSx® Laser brings a new level of precision to these surgical steps through a number of high-tech features:
Real-time video imaging with integrated OCT. Provides three-dimensional visualization of the entire anterior segment during docking, planning and procedure.
Curved patient interface. Designed for patient comfort, ease of use and optimal laser performance.
Intuitive touch screen graphic user interface. Allows each step of the procedure to be easily planned, customized and executed.
True image-guided surgical planning. Enables the surgeon to precisely program the size, shape and location of each incision.
How is a femtosecond laser used to assist in cataract surgery?
Currently, FDA-approved for 3 steps: All corneal incisions Anterior capsulotomy Lens fragmentation
But, why is this important?
Laser-assisted Cataract Surgery
Corneal Incisions Anterior capsulotomy Lens fragmentation
Limitations of Traditional Cataract Surgery
Laser-assisted Cataract System
Femtosecond Laser
Offers a new level of precision and reproducibility in ophthalmic surgery
Helps to optimize the capsular and corneal incisions
1. Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at: Annual Meeting of the American Academy of Ophthalmology; October 24-27, 2009;
2. Nagy, ZZ. Intraocular femtosecond laser applications in cataract surgery. Cataract & Refractive Surgery Today. September 2009:79-82. San Francisco, CA.
Real-Time Images
Integrated Imaging
LenSx® features an onboard, proprietary optical coherence tomographer (OCT) in conjunction with a video microscope, to provide three-dimensional visualization of the anterior segment. It can visualize multiple views, including:
Side View, Capsular Bag
Topographic View, Lens
Side View, Cornea
Imaging
Catalys also includes integrated OCT LensAR uses ray-tracing technology for
3D visualization
SoftFit Patient Interface
A disposable, single-use, soft contact lens is used to dock with the patient's eye.
This curved patient interface is designed for patient comfort, ease of use, and optimal laser performance.
Surgeons guide and gently dock the disposable patient interface using the video microscope and integrated real-time OCT.
The unique shape of the patient interface helps maintain a more natural curvature of the patient's cornea. This helps to improve surgical accuracy during the LenSx® Laser procedure.
Docking Interface
Both Catalys and LensAR have a low-pressure fluid-filled docking system
Laser-assisted Cataract Surgery
Corneal Incisions Anterior capsulotomy Lens fragmentation
Laser-assisted Cataract Surgery
Corneal IncisionsPrimary and Secondary Incisions
Astigmatism Anterior capsulotomy Lens fragmentation
Manual Clear Corneal Incisions
Imprecise tunnel length and geometry Frequently require stromal hydration to
seal wound, which induces corneal edema
Poor wound construction may lead to snowball effect of intraoperative difficulties (anterior chamber maintenance and fluid dynamics)
Incisions may be unstable, which may lead to increased risk of infectionBehrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds after
phacoemulsification surgery using optical coherence tomography in the early postoperative period. J Refract Surg, 2008;24(1):46-9Taban M, Behrens A. Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of literature. Arch Ophthalmol. 2005;123(5):613-20
Manual Corneal Incisions
Corneal Incisions
Primary and secondary incisions (including arcuate incisions) can be created
Size and degree of each incision and its orientation are customizable
Single-plane cut
Two-plane cut
Three-plane cut
Laser Corneal Incisions
Laser-assisted Cataract Surgery
Corneal IncisionsPrimary and Secondary Incisions
Astigmatism Anterior capsulotomy Lens fragmentation
Astigmatism in Cataract Patients
Arcuate Incisions
Manually created using handheld diamond blade
Inconsistent depth control
Risk of perforating cornea
Unpredictable effect due to imprecise wound architecture and depth
No image-guided planning or visualization
Laser Arcuate Incisions
Image-guided surgical planning with OCT
Real time corneal thickness Computer-customized
incisions % depth Incision length and
position 3D visualization of incision
placement Predictable incision width Titratable incisions
(adjustable intraoperatively and post-operatively in office)
Laser Arcuate Incisions
Laser-assisted Cataract Surgery
Corneal Incisions Anterior capsulotomy Lens fragmentation
Anterior Capsulotomy
Continuous and perfectly curvilinear Potentially stronger with lower likelihood
of anterior capsular tears
Anterior Capsulotomy Only 10% of manually created
capsulorhexis achieved a similar diameter accuracy of +/-0.25 mm vs. nearly 100% of LenSx procedures
Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at: Annual
Meeting of the American Academy of Ophthalmology; October 24-27, 2009; San Francisco, CA.Nagy, ZZ. Intraocular femtosecond laser applications in cataract surgery. Cataract & Refractive Surgery
Today. September 2009:79-82.
Why does this matter?
Anterior Capsulotomy
Effective Lens Position
Effective Lens Position“The key to highly accurate IOL power
calculation is being able to correctly predict ELP for any given patient and IOL”
Studies show that the size of capsulorhexis affects ELP
Capsulorhexis needs to be round, centered, and just smaller than the IOL optic diameterHaigis W, Lege B, Miller N, Schneider B. Comparison of immersion ultrasound biometry and partial
coherence interferometry for IOL calculation according to Haigis. Graefes Arch Clin Exp Ophthalmol, 2000;238:765-73Cekic O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers, 1999;30(3):185-90Hill WE. Hitting Emmetropia. Chang D. (ed) In: Mastering Refractive IOLs – The Art and Science. Slack, Incorporated, 2008Hill WE. Does the Capsulorhexis Affect Refractive Outcomes? Chang D. (ed) In: Cataract Surgery Today, Bryn Mawr Communications, Wayne, Pennsylvania 2009, p.78
Capsulotomy
Using the available laser systems, it is possible to precisely center the capsulorhexis and determine the diameter and depth of the anterior capsulotomy.
Capsulotomies
Manual
Femtosecond Laser
LenSx® Laser vs Manual CCC
Non-randomized, prospective, single site, single surgeon study
With single lens type, ALCON monofocal SN60WF
Manual group (n=26) Attempted 5.0mm manual capsulotomy
LenSx Laser group (n=22) Femtosecond laser created 5.0mm capsulotomy
Accuracy to Target, Actual ELP No significant difference in baseline between
cohortsRobert J Cionni MD. Presented AAO 2011 Refractive Sub-Specialty Day, “Comparison of Effective Lens Position and Refractive Outcome: Femtosecond Laser vs Manual Capsulotomy”
Predicted vs Real Refraction
Actual vs Predicted ELP
Laser-assisted Cataract Surgery
Corneal Incisions Anterior capsulotomy Lens fragmentation
Lens Fragmentation
The femtosecond laser performs lens fragmentation, creating easily dissected segments for efficient removal with reduced phaco power.
Most systems allow the surgeon to set the lens fragmentation pattern, from pie cuts to complete liquefaction.
Lens Fragmentation Patterns can be customized for the
cataract type Spares ultrasonic power and time
Other Peer-Reviewed Publications
Ecsedy M, Miháltz K, Kovács I, Takács A, Filkorn T, Nagy ZZ, Effect of Femtosecond Laser Cataract
Surgery on the Macula, Journal of Refractive Surgery, 2011;27:717-722.
Miháltz K, Knorz MC, Alio JL, Takács A, Kránitz K, Kovács I, Nagy ZZ, Internal Aberrations and
Optical Quality After Femtosecond Laser Anterior Capsulotomy in Cataract Surgery, Journal of Refractive Surgery, 2011;27:711-716.
Nagy ZZ, Kránitz K, Takács A, Miháltz K, Kovács I, Knorz MC, Comparison of Intraocular Lens
Decentration Parameters After Femtosecond and Manual Capsulotomies, Journal of Refractive Surgery, 2011;27:565-569.
Kránitz K, Takács A, Miháltz K, Kovács I, Knorz MC, Nagy ZZ, Femtosecond Laser Capsulotomy and
Manual Continuous Curvilinear Capsulorrhexis Parameters and Their Effects on Intraocular Lens Centration, Journal of Refractive Surgery, 2011;27:559-563.
Nagy ZZ, Takács A, Filkorn T, Sarayba M, Initial Clinical Evaluation of an Intraocular Femtosecond
Laser in Cataract Surgery, Journal of Refractive Surgery, 2009;25:1053-1060
Summary
Image-guided femtosecond laser designed specifically for refractive cataract surgery
Using a customizable 3-D surgical platform, it allows visualization, customization and completion of many of the most challenging steps of cataract surgery: Anterior capsulotomy Lens fragmentation All corneal incisions
Thank you!