Users provide insights on lens removal with 'kinder, gentler' AquaLase

Chicago-Cataract surgeons experienced with the AquaLase platform of the Infiniti Vision system (Alcon Laboratories) agree that it offers multiple advantages that make it leading technology for small incision lens removal in properly selected patients.

The surgeons discussed their case selection criteria, techniques for lens removal using AquaLase, and outcomes at an Alcon-sponsored AquaLase Users Roundtable.

Robert Lehmann, MD, Nacogdoches, TX, who served as the moderator, summed up AquaLase as providing a “kinder, gentler method for lens removal.”

“When I was first introduced to this technology, I embraced it because of its potential safety advantages. AquaLase allows lens removal without thermal issues and with less potential damage to the endothelium and posterior capsule, and the postop results are incredible. I use it routinely in patients with up to a grade 2+ cataract and I consider it a top-shelf procedure for my patients who are undergoing refractive lens exchange. These latter individuals have extremely high expectations, and this technology is delivering the satisfaction I am looking for,” he said.

The participants discussed parameters for selecting patients who will benefit from the potential advantages of the AquaLase procedure. Age and nuclear density are the primary factors as AquaLase is generally best suited for surgery in eyes with softer nuclei versus more moderate to dense cataracts, they said.

Age cutoffs for various roundtable participants ranged from 65 to 75 years old and most limited this technique to patients with a cataract density up to 2+, although some surgeons noted they use AquaLase to remove harder lenses. Notably, the participants agreed that age, overall, may be a better criterion for AquaLase patient selection than density since the latter feature can not always be judged accurately by appearance at the slit lamp.

Since its introduction, there has been an evolution in the AquaLase lens removal technique. Currently, most participants in the discussion favored a prechop technique that allows highly efficient cataract removal. However, Jing Dong, MD, PhD, Athens, GA, described his “back crack” technique, which he says in his hands is slightly more efficient than prechop and helpful with slightly harder nuclei. Its advantages include safety-no sharp instruments are needed; efficiency-there is no need to change instruments; and absence of a learning curve-the technique is the same as that used in phaco, Dr. Dong said.

With its efficiency and stable fluidics, AquaLase has the potential to minimize endothelial cell loss when performed in appropriately selected patients. Rolando Toyos, MD, Jackson, TN, presented supporting data for that concept from a study he performed. Dr. Toyos found that in patients aged 70 years old and younger, the average endothelial cell loss rate after an AquaLase procedure was 3% to 4%, which was lower than the 10% rate found in patients within the same age group who had ultrasound phacoemulsfication. Among patients in their 70s, there was less difference between the two technologies, and for those older than age 80, ultrasound was a faster procedure and associated with less endothelial cell loss, he reported.

The AquaLase procedure is also very friendly to the posterior capsule, but another of its potential advantages is that it can be used to “power wash” lens epithelial cells. Therefore, it is being looked to for its potential to reduce posterior capsule opacification (PCO). Since long-term follow-up is needed to characterize any benefit for AquaLase surgery in reducing PCO rates, Dr. Toyos used a pediatric cataract case as a study model to investigate this issue.

He reported having performed AquaLase in one eye and phacoemulsification contralaterally in a child undergoing bilateral cataract surgery. After 1 year, the posterior capsule in the AquaLase eye remained clear whereas Nd:YAG laser capsulotomy had already been performed in the fellow eye.

“Preservation of the corneal endothelium and maintenance of a clear posterior capsule are important considerations as lens removal surgery is being performed more and more as a refractive procedure in younger patients,” Dr. Toyos noted.

In studies he performed in the laboratory, Dr. Toyos also found that it was possible to re-enter the eye with the AquaLase handpiece to remove retained nuclear fragments without causing damage to an already implanted IOL.

“Once you have implanted the lens, you cannot go back with the ultrasound handpiece to remove nuclear fragments,” he said.