Femtosecond laser assistedcataractsurgery

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




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


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



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



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!

Health & Medicine

Femtosecond laser assistedcataractsurgery