Femtosecond laser cataract surgery using broad inclusion criteria

TAKE HOME: Outcomes from use of a proprietary femtosecond laser system (Catalys Precision Laser System, OptiMedica) to perform cataract surgery in a series of 850 eyes, of which 25% have some comorbidity, are testament to its reliability and safety.

San Francisco-Femtosecond laser cataract surgery using a proprietary system (Catalys Precision Laser System, OptiMedica) is associated with excellent results whether operating on routine cases or patients with co-morbidities.

In fact, it is in the complex cases where the laser may provide some of its greatest benefits, according to Burkhard Dick, MD, PhD, who presented findings from a large prospective review of his personal experience with the laser at the annual meeting of the American Society of Cataract and Refractive Surgery.

The series comprised the first 850 consecutive cases performed by Dr. Dick, professor of ophthalmology and chairman, Ruhr-University of Bochum, Bochum, Germany. They represented the entire spectrum of nuclear density, including 405 eyes with grade 4 cataract (LOCSIII scale) and 31 eyes with a mature intumescent cataract. Overall, 26% of cases presented with some comorbidity or feature that could confound safety of conventional cataract surgery.

Within the series there were 53 eyes with glaucoma, 72 eyes with corneal pathology (Fuchs’ dystrophy, corneal guttata, scars), 102 eyes with pupil issues (small pupils, intraoperative floppy iris syndrome), 50 eyes at risk for loose zonules due to pseudoexfoliation syndrome or history of pars plana vitrectomy, and 91 cases where patients were on anticoagulant medication.

Summarizing outcomes, Dr. Dick noted that a complete capsulotomy was achieved in 99% of eyes, 40% of cases were completed with no ultrasound energy, and for the 836 eyes with grades 2 to 4 cataracts, mean effective phaco time was reduced by 96% compared with historical controls operated on with standard manual techniques. There were few complications.

“In our series where about one-fourth of eyes had some comorbidity, we would expect to encounter a much higher complication rate using a standard phaco technique,” Dr. Dick said. “However, cataract surgery with this femtosecond laser has great safety thanks to the laser’s precision, OCT guidance, and effective lens fragmentation that reduces ultrasound use.”

The complications encountered included 2 tags in eyes with mature cataract where surgery was performed with ophthalmic viscoelastic device in the anterior chamber, 5 tags in eyes with a small pupil, and 9 cases of conjunctival alterations, all in patients on an anticoagulant.

“The laser’s Liquid Optics patient interface works well in all eyes, including pediatric cases and patients with strabismus or previous filtering surgery,” Dr. Dick said. “It allows a gentle dock, increasing IOP by only about 10 mm Hg after application of the suction ring.”

Approaching near elimination of ultrasound

Despite achieving good results from the beginning, Dr. Dick aimed to refine his procedure over time. He first optimized the surgical technique and fragmentation pattern for lens softening and then switched irrigation and aspiration tips and phacoemulsification machine settings while adopting a new mindset about the need for routine phaco energy.

Each successive change led to a progressive decrease in ultrasound energy usage as shown by an analysis comparing three groups of 200 consecutive cases performed over time (mean LOCSIII scores 3.4 to 3.5). Dr. Dick noted using no ultrasound in 41% of cases 200 to 400, 72% of cases 700 to 900, and 91% of cases 1,200 to 1,400.

Dr. Dick also uses the laser to make precise corneal incisions, including to create the cataract surgery incisions and for astigmatic correction, and he has begun to apply the laser for performing posterior capsulotomy and the bag-in-the-lens technique.

Burkhard Dick, MD, PhD

E: dickburkhard@aol.com

Dr. Dick is a consultant to Abbott Medical Optics, AcuFocus, Allergan, Aquesys, Bausch + Lomb, Calhoun Vision, Carl Zeiss Meditec, Domilens, Geuder, Morcher, Novartis, Oculus, Ophtec, Optical Express, OptiMedica, and PowerVision.

Novel model for cataract patients

Mercy Clinic Eye Specialists, Springfield, MO, recently installed two Catalys Precision Laser Systems (OptiMedica) at its surgery center. The practice is unique in the ophthalmic industry in that it is offering the femtosecond laser technology to all patients seeking cataract surgery at no additional charge to the patient. Shachar Tauber, MD, chairman of ophthalmology and director of ophthalmic research and telemedicine, discusses why Mercy Clinic Eye Specialists chose to implement its cataract surgery program in this manner, and how this novel model is received by patients.