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W e incorporated femtosecond laser- assisted cataract surgery into our practice a year ago, and it has been a wonderful addition that has changed almost everything about routine cataract surgery. In our OR, the Catalys (Abbott Medical Optics, Santa Ana, Calif.) sits right next to the microscope and the Signature unit. The femto part of the procedure includes the incisions, the fragmentation, and the capsu- lorhexis. The great thing is that the parts of the procedure that use the most energy and have the most potential for surprise are done with the femtosecond laser. It's a whole new puzzle to look at because the tricky parts are already done. Immediately after we started using the femtosecond laser, we found that the rhexis was incredibly strong and forgiving. The lens came out in such a way that we changed the way we approached the phaco unit. The phaco unit was no longer a huge engine that required a lot of ultrasound energy. Once we under- stood that, we had to change our parameters for phaco, and I didn't use the same divide-and-conquer or cracking technique simply because it wasn't necessary. It was excessive, and it didn't make sense. The first thing we noticed was that phaco time decreased dramatically. We have five surgeons in my practice, and we all have very different ways to approach a cataract. One surgeon does divide- and-conquer. We have crackers and splitters, and we have a doctor who essentially bowls out the cataract. We quickly saw not only the phaco times go down, but also the amount of infusion of fluid going into the eye. We never change bottles any- more, and we used to have about 200 mL of balanced salt solution going into the eye. With the femto laser, the lens is already divided up once the phacoemulsification process begins. Prior to femto, we were very com- fortable with peristaltic. We knew how to have a rock steady chamber, and we knew how to do our different techniques. None of us really had experience with Venturi, but the Venturi side of the machine works quite well. Cubes are becoming popular with all of the femto lasers for dividing up the lens, and we got them consistently from day 1. Out of the box, we were making these cubes, 350 to 500 depending on the consistency of the lens, and it took a little bit of time for us to understand that a 40-year-old with a posterior subcapsular cataract is different from a 90-year-old with a "catarock"—a 4+ brunescent cataract. But getting the cubes to come in, by telling the femto to cube it in such a way, has made the disassembly very controlled. Use caution because the cubes are very small, and sometimes they will park themselves in the paracentesis. As we are implanting the IOL, we will put some viscoelas- tic through the paracentesis, and every so often, a little cube comes out. It comes out very easily with I/A, but that control piece is won- derful. With Venturi, you have to be patient. You can't go fishing like you do in peristaltic. There is value in being able to switch from peristaltic to Venturi. Most of us have come from peristaltic, so there is a sense of comfort with it. The ideal situation is to remove the first piece with peristaltic, remove the two other quadrants with Venturi, and then go back to peristaltic. It's a nice transition. There are certain in- stances where different techniques do better. In phaco flip techniques, I think peristaltic would do better, but I don't think that long term we will see a lot of peristaltic surgeons out there. The more complex surgeries that we see, which is really where the femto has no competitor, is where surgeons are going to want their Venturi. This is the future of cataract surgery in our opinion. Last month, we completed our first year of this, and we have enjoyed the added precision and accuracy. It has been a great addition to our practice. Dr. Tauber is the section chair of ophthalmology at Mercy Eye Center in Springfield, Mo. He can be contacted at shachar.tauber@mercy.net. by Shachar Tauber, MD Changing the approach to lens extraction with femtosecond laser-assisted cataract surgery " We had to change our parameters for phaco, and I didn't use the same divide- and-conquer or cracking technique simply because it wasn't necessary." Shachar Tauber, MD 5 With the femto laser, the lens is already divided up once the phacoemulsification process begins. Laser-assisted cataract surgery

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