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Sangeeta Abrol

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Sangeeta Abrol MS, 2Neeraj Varma MS
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phacomachines, biometers, corneal topography tools
and innovations in intraocular lens implants have enabled
they seal and heal well. These self-sealing incisions allow
considerable waiting time before commencing removal of
nuclear fragments in the OR. Arcuate incisions are possible
us to give better results to our cataract patients in terms of in sub-Bowman corneal stroma, while leaving the corneal
          ! _      epithelium and Bowman layer intact.3 The length, depth
enabling early rehabilitation. The improved results are also a        ^       ! 
_ * !   
 L incisions decrease the risk of epithelial ingrowth and
perfectly centered capsulorhexes, properly placed implants   ^     C  L  
   !      _   other hand, are affected by certain variables like surgeon’s
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is a work of art, which today is individualized for each complication of an occasional corneal perforation.3,4,5
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surgical procedure worldwide has become so successful and
on the visual axis is created by laser spots placed in a
C  {     {   
circumferential fashion. Barring one or two small tags to the
patients are getting higher and higher leaving no room for
peripheral capsule similar to postage stamp attachments,
  * !L  !L €  
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anaesthesia, bandaging of eyes, bed rest for days together
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and restrictions on activities of several kinds are things of the
intumescent cataracts, even for the experienced surgeons is
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much easier with laser.
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want to get back to work and resume their normal activities  !L _ ! 
soon after. Despite extraordinary results with the use of newer are performed based upon a programmed algorithm that
  _L{C ! produces pie-shaped fragments that work better for a hard
Ophthalmology and caused tremendous excitement in the nucleus and spherical-based or cubicle-based fragments that
ophthalmic community is femtosecond laser technology for C*C/_@L
cataract surgery. a three chop (six segments) or a four chop (eight fragments)
        ^  
What is Femtosecond Laser Assisted Cataract made segments planned, lengthier is the procedure. The
Surgery (FLACS)? nuclear fragments are manually removed in the OR with
Femtosecond laser technology is already being used as an a phaco hand-piece with or without the use of ultrasound
alternative to manual and mechanical methods of creating energy. Soft nuclear material can be aspirated with irrigation-
a corneal incision for laser in situ keratomileusis (LASIK) aspiration hand-piece. Nucleus removal thus becomes safer
procedures, the so called “Blade-less LASIK” or “All-laser- and faster and there is reason to believe that incidence of
LASIK” and its advantages as we all know are real. The same complications like posterior capsular rent and vitreous loss
laser is being used now to perform some of the steps of cataract is low.
surgery in the laser room like making clear corneal incisions, Once the eye is pre-treated in the laser room to create
performing anterior capsulorhexis, lens fragmentation and if main port, side port, anterior capsulotomy and fragments
_ L * !        !  of nucleus, the patient is wheeled into the OR where the
correction.1 Rest of the surgical steps like removal of nuclear       L        
fragments, cortical aspiration and intraocular lens (IOL) removed, nuclear fragments are aspirated out, cortical clean
implantation are carried out in the operating room (OR). up is done and desired IOL is implanted in the bag. Wound
     /@    hydration is also carried out before the patient is wheeled out
for astigmatic keratotomy performed with femtosecond of the OR.
laser are regular, smooth, reproducible and have consistent
Laser Cataract Technology Platforms
outcomes with minimum collateral damage.2 Single or three-
plane incisions can be created, the latter being more stable. As of now, there are four laser technology platforms that are
Some surgeons prefer to make trapezoidal incisions locating available and one of these is also approved by Food and Drug
them peripherally enough to touch the limbal vessels as Administration (FDA) of USA for commercial use.

www. dosonline.org l 37
  # Œ} Œ $  /Œ}L -L '  *L
Florida) integrates an advanced refractive cataract laser
with proprietary 3-D confocal structured illumination
/$-@ !      L  ?~
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system produces seamless high-resolution, high-
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to the posterior capsule. The technology automatically
builds a 3-D model of the anterior segment, using
ray tracing with ocular media refractive indexes, and
calculates optimal cutting patterns across all grades
of cataract. The LensAR laser system is ergonomically
designed and mobile, with three touch-screens for
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interface does not directly touch the cornea, thereby
preserving the eye’s natural anatomy.
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Fort Worth, Texas)7 enables surgeons to perform key
Figure 1: Technolas workstation steps of cataract surgery with image-guided visualization
and micron-level laser precision. According to Alcon,
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designed to fragment the lens nucleus, perform a perfectly
sized and centered capsulotomy, and create all corneal
incisions. The LenSx Laser has integrated proprietary
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anatomy and allow precise localization of surgical laser
pulses. It is a fully-integrated, image-guided femtosecond
 !   ! 
Using a customizable 3-D surgical platform, it allows the
surgeon to visualize, customize and perform many of the
most challenging steps of cataract surgery. It provides
Figure 2: Curved patient interface    ! !C  !|#C
three-dimensional visualization of the entire anterior
segment during docking, planning and procedure. The
curved patient interface is designed for patient comfort,
 #      Π$  /| ^  ease of use and optimal laser performance. Whereas an
L $ L   @     intuitive touch screen graphic user interface allows each
rapid femtosecond laser, integrated optical coherence step of the procedure to be easily planned, customized
!  /|#@ ! !L  | ^ [  and executed, the true image-guided surgical planning
scanning technology. According to the company, feature enables the surgeon to precisely program the
this laser is capable of performing capsulotomy, lens size, shape and location of each incision. This is an FDA
fragmentation, arcuate relaxing incisions, and cataract approved device and is being commercially used.
   # !  *     Benefits of Laser Cataract Surgery
      Π_  |  -
that optimizes the optical path to the patient’s eye and Femtosecond laser–assisted cataract incisions may offer
a proprietary Integral Guidance System that ensures the added stability and reproducibility in cataract wound
femtosecond laser pulses are delivered precisely to the    L      
intended location. generated with ultra-sharp blades in a single pass (with or
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Germany)6 is a modular addition to the Technolas are potentially physically unstable, allowing leakage from
Femtosecond Workstation for performing cataract deformation of the eye (eye rubbing, forceful blinking) early
and refractive surgery with one device. According after surgery. The femtosecond laser produced capsulotomies
   L     are more precise, accurate, reproducible, and stronger than
was designed to perform anterior capsulotomy, lens   C       _7,8,9,10
fragmentation, corneal incisions, and arcuate relaxing Secondly, cataract patients can achieve refractive goals with
incisions. The Technolas Femtosecond Workstation can the help of femtosecond laser. Some workers have shown
-LŒ$-L     !       
and be used for other corneal therapeutic indications.       /"Œ@L  {      !
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Interface, which keeps corneal deformation to a minimum in favour of laser cataract surgery.10,11 A more accurately
to allow precise 3-D cutting. The system’s built-in, online positioned IOL reduces the need for exchanges and
|#      ! /   Œ$-}#
cuts) and monitoring (position of cuts) of the cataract advantages of automating certain surgical steps are precision
procedures. and reproducibility.

38 l DOS Times - Vol. 17, No. 7 January, 2012

 patients and practices will need to convert a large volume of
patients to laser cataract surgery to be commercially viable.
 L!   
pay only for a standard cataract procedure with implantation
!-|Œ^ L 
pays for astigmatism-correcting or presbyopia-correcting
IOL. And now the patient will have to accept to pay additional
expenses for undergoing certain integral steps of a standard
  C 

Who needs FLACS – Patients or Ophthalmologists?

  
by a reasonably skilled surgeon are outstanding. Freshly
trained residents from institutes of repute perform routine
Figure 3: Real-time high contrast Optical
 !  C  !    
Coherence Tomography (OCT)
translates into remarkable patient satisfaction. Even manual
     !  /^$-$@  C 
care can match astonishing results of an uneventful phaco
surgery. All said and done, patients ultimately need good
Complications and Contraindications visual recovery with no discomfort whatsoever. To most of
Despite high success rate, there are certain complications7  L _!  
that can occur with the use of femtosecond laser. They are in fact may not matter as long as they are seeing pretty well
decentration of incision, capsulotomy or phacofragmentation; and results are as per their expectations. On the other hand,
incomplete or interrupted capsulotomy, fragmentation, or most of us are pretty much comfortable with our current
corneal incision procedure; capsular tear; corneal abrasion or !  _C#_   C
™_*™ ™ a burdensome capital expense only to impart a minimal
intraocular pressure; damage to intraocular structures; enhancement in visual results? Or is it an overenthusiastic
haemorrhages and infection. Intraoperative capsular block Ophthalmologist with a clever entrepreneur in him or her
  /K$@  !        trying to sell a new and developing technology to gullible
uncommon but potentially serious complication that can patients?
result in posterior capsule rupture and posterior dislocation
of the crystalline lens during cataract surgery. However, Conclusion
#  CK$C OŒ$8    L        OŒ$  
There are certain contraindications7 for this procedure   ! #!  ! !
such as corneal diseases that preclude applanation of the established and may take some more time to get a strong
cornea or transmission of laser light at 1030 nm wavelength; foothold.10 There is lack of peer-reviewed studies of its use.
descemetocele with impending corneal rupture; presence Even in the developed world there are a handful of surgeons
of blood or other material in the anterior chamber; poorly who have adopted it and those who have and are advocating it
dilating pupil such that the iris is not peripheral to the are paid consultants to the companies that have launched the
intended diameter for the capsulotomy; conditions which technology. Only time will tell whether this laser technology
C  _  C   will be adapted into standard ophthalmic practice in the
capsulotomy depth and the endothelium (applicable to C   "" 
capsulotomy only); previous corneal incisions that might treatment of cataracts. In Indian context where not many non-
provide a potential space into which the gas produced by     
   ™   * _  procedure with a foldable implant, leave alone premium
that are beyond the range of the system; corneal opacity that -|Œ™ ^$-$   !    { ™
would interfere with the laser beam; hypotony, glaucoma, or market is very price sensitive and capital investment is
the presence of a corneal implant; residual, recurrent, active unthinkable for many of us, it will take several years before
ocular or eyelid disease, including any corneal abnormality OŒ$#!! 
(for example, recurrent corneal erosion, severe basement has been evolving, it cannot change in a femtosecond.
membrane disease) and lastly, this device is not intended for
References
use in pediatric surgery. 1
Slade S. Do We Need Laser Cataract Surgery? Cataract and Refractive
Economic Considerations Surgery Today. Sept 2011: 64
2
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%‰€"
This brand new technology meant to assist a traditional
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 $*
%]%*=Q//P@(PK
consumables (about Rupees Thirty Thousand per case) and
4
the comprehensive maintenance contract (about Rupees Masket S. Is there a relationship between clear corneal cataract incisions
Seventy Lac per annum)apart from the cost for physical space and endophthalmitis? [Guest editorial]. J Cataract Refract Surg.
needed to accommodate and operate the laser is phenomenal. =QQ?<>/8@>8@?
5
In economic terms, the affordability of femtosecond laser Masket S. Sarayba M, Ignacio T, Fram N. Femtosecond laser-assisted
depends on its cost, the expected revenue, and the minimum    \ % \ %
return on investment. The cost of integrating this technology *
=Q/Q<>8/Q@K(/Q@3
in clinical practice will have to be eventually passed on to the 6
 $ \   $A\=?=Q//

www. dosonline.org l 39
 7 10
 $ \   ` A\=?=Q// Cionni R. Six months’ experience with laser cataract surgery. Cataract
K
 ]% | *  " '     ()  *   \  and Refractive Surgery Today. Sept 2011: 67-69
11
%   
% Nagy Z, et al. Comparative analysis of femtolaser-assisted and manual
*
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9
 ^ #Y  A|* "  A^   Congress of the European Society of Cataract and Refractive Surgeons;
 %*
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Monthly
M onthly C
Clinical
linical M
Meeting,
eeting, January
January 2201
012
Venue: Auditorium, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi-110060
Date & Time: 29th January 2012 (Sunday) 10:30 a.m.

Clinical Session: 10:30 a.m.

Clinical Cases:
1. Orbital Mucormycosis – Saving life! : Dr. Nayanshi 8 min.
Discussant : Dr. Shaloo Bageja

2. Posterior Scleritis- End of a painful journey! : Dr. Rohini 8 min.

Discussant : Dr. Neeraj Manchanda
Clinical Talk:
Why this? Why this? Kolaveri Di ! : Dr. A.K. Grover 20 min.
- Ethics and the practice of Ophthalmology

Mini Symposium: Small is Beautiful

Chairman: Dr. A.K.Grover, Co-Chairman: Dr. Harbansh Lal

1. Micro incisions Coaxial Cataract Surgery –The Era of : Dr. Harbansh Lal 15 min.
Bimanual surgery is over!
2. Sutureless Vitrectomy - 23 Gauge-25 gauge- or…………….? : Dr. Amit Khosla 15 min.
3. Eyes are beautiful – Retain the eternal beauty!! : Dr. A.K. Grover 15 min.
- Ocular Aesthetics and more aesthetics approaches
Panel Discussion
The year 2012: Looking back at the last 25 years and ahead at the next ten!
Panelists: Dr. H.K. Tewari, Dr. K.P.S. Malik, Dr. N. Shroff, Dr. B. Ghosh, Dr. Amit Khosla
Something to Savour: Food for Stomach!
20 Early Bird prizes for members arriving before 10.30 A.M
Courtesy: Optho Remedies

40 l DOS Times - Vol. 17, No. 7 January, 2012