How femtosecond laser anterior capsulotomy can preserve capsular integrity in IOL exchange

Take-Home: When performing IOL exchange in eyes with anterior capsule phimosis, use of a femtosecond laser to create a secondary anterior capsulotomy can allow in-the-bag placement of the new IOL.

Reviewed by Samuel Masket, MD

Los Angeles-Findings from multiple studies demonstrate benefits of using a femtosecond laser for anterior capsulotomy during cataract surgery.

Building on that application, the femtosecond laser also provides a useful tool for creating a secondary anterior capsulotomy to assist with intraocular lens (IOL) exchange complicated by anterior capsule phimosis, said Samuel Masket, MD.

Crediting Surendra Basti, MD, Northwestern University, Chicago, for first describing the procedure, Dr. Masket has performed femtosecond laser secondary anterior capsulotomy successfully in two patients using different femtosecond laser platforms (Catalys Precision Laser System, Abbott Medical Optics; LenSx Laser System, Alcon Laboratories).

The first case, which involved a patient who was three-years, post-cataract surgery, also reinforces the importance of careful patient selection when implanting multifocal IOLs, said Dr. Masket, clinical professor, Jules Stein Eye Institute, UCLA School of Medicine, Los Angeles.

The patient was a 75-year-old woman referred to him because of dissatisfaction with her vision after bilateral multifocal IOL implantation with a three-piece acrylic multifocal IOL. The patient had ocular surface disease, including both epithelial basement membrane dystrophy and severe dry eye disease, along with dry age-related macular degeneration. Although her binocular BCVA was only 20/50, she was expected to benefit from the IOL exchange because her potential acuity measured with a retinal acuity meter was 20/25.

Challenges expected

Challenges expected

Nevertheless, Dr. Masket expected the procedure would be challenging because of significant anterior capsule phimosis.

“Explanting an IOL after three years can be fraught with problems because there may be adhesions between the haptics and capsular bag,” Dr. Masket said. “This case was further complicated by a shrunken and fibrotic anterior capsule.

“The conventional choices are to make relaxing incisions with an Nd:YAG laser in the office preoperatively or with scissors intraoperatively,” he explained. “Either of those approaches, however, may render the capsular bag unusable for secondary IOL implantation. Using the femtosecond laser to cut a secondary capsulotomy makes it possible to retain a normal capsular bag.”

Using the Catalys femtosecond laser and with the same parameters that he sets for primary capsulotomy (except that the energy was increased from 6.0 mJ to 10.0 mJ), Dr. Masket created a 4.8-mm secondary anterior capsulotomy. Once the patient was in the operating room, he created a 2.2-mm temporal clear cornea incision. Then, he used a microforceps to free the laser-cut anterior capsule edge and a spatula to separate the anterior capsule from the underlying anterior surface of the IOL.

“After these maneuvers, it was not difficult at all to peel away the secondary capsulotomy,” Dr. Masket added.

With blunt and viscodissection, Dr. Masket then separated the capsule from the anterior surface of the lens for 360°. With a Sinskey Hook, he elevated one edge of the optic.

Blunt and viscodissection were used to free the inferior haptic that was firmly attached to regenerative cortex. The superior haptic was free of adhesions.

The IOL was cut and removed. After ensuring that the capsular bag was opened 360°and regenerative cortex was removed, intraoperative aberrometry (ORA System with VerifEye+, Alcon Laboratories) was used to guide power selection for a single-piece acrylic monofocal IOL.

Six months after the procedure, the monofocal IOL was perfectly centered, there was no anterior capsule phimosis, and the patient had 20/25 UCVA. The procedure was repeated in the second eye with the same good result.

Maximizing success

Maximizing success

Dr. Masket pointed out that the first patient should not have been implanted with a multifocal IOL because her ocular comorbidities made her a poor candidate for achieving a good outcome.

“Proper patient selection, along with thorough preoperative counseling to set appropriate expectations, are two of the guiding principles for achieving patient satisfaction after multifocal IOL implantation,” Dr. Masket said.

“Proper patient selection involves avoiding anyone who has any of the following conditions that I collectively describe as ‘the opathies’ – keratopathy, optic neuropathy, zonulopathy, pupillopathy, maculopathy, and psychopathy,” he added.

Even when surgeons are proactive and practice good candidate selection, they may need to react postoperatively to handle a patient who is dissatisfied after multifocal IOL implantation. Management of those cases requires understanding of the possible causes for a suboptimal outcome, which include residual refractive error and ocular surface disease among other issues, along with supportive counseling as patients adapt to multifocal IOL vision.

“Importantly, good postoperative management skills also require that surgeons know when and how to exchange the IOL,” Dr. Masket said. “If everything else fails and the patient still has poor quality vision, then it is best to exchange the IOL.”

Samuel Masket, MD

E: avcmasket@aol.com

This article is based on a presentation given by Dr. Masket at the 2016 ASCRS Annual Meeting. Dr. Masket is a consultant for Alcon Laboratories and receives speaking honoraria from MicroSurgical Technology.