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Femtosecond surgeon and phacoemulsification surgeon team up to get the most out of laser cataract surgery E fficient utilization of expensive operating suites is mandatory for all ASCs and hospitals. It is obvi- ously impossible for one surgeon to simultaneously perform both femtosecond laser and pha- coemulsification surgery. We have therefore employed a schedule that permits one of us to perform the femtosecond treatment while the other continues to use the operating room for completion of the phacoemulsification and the IOL implantation procedure. At our practice, Dr. R.J. Mackool performs the LenSx Laser (Alcon, Fort Worth, Texas) surgery, while Dr. Richard Mackool is performing pha- coemulsification with the INFINITI system (Alcon). The patient is then transported to the operating room where either Dr. R.J. Mackool or Dr. Richard Mackool completes the pro- cedure. Because the surgeon who does the LenSx Laser procedure doesn't necessarily have to do the phacoemulsification, the OR runs continuously and efficiently. We believe that the most diffi- cult part of phacoemulsification is dividing the nucleus, and the ability of the LenSx Laser to fragment the lens prior to phacoemulsification is a major advantage. In our experi- ence, we have observed the manual completion of nuclear division is subsequently performed with less effort and stress on the zonule. It is likely one of the reasons the effec- tive lens position (ELP) of the IOL has been shown to be more pre- dictable after LenSx Laser cataract surgery. 1 The ability to reduce zonu- lar stress can be of critical impor- tance in eyes with pre-existing zonular laxity, e.g., pseudoexfolia- tion. The LenSx Laser is capable of performing both radial and cylindri- cal fragmentation patterns. The nu- cleus can therefore be fragmented in order to create either four or six seg- ments, and these segments can be further divided utilizing cylindrical laser application of various diame- ters. After femtosecond treatment of the nucleus, the completion of nu- clear division can usually be accom- plished without significant sculpting of the nucleus. The reduction of ul- trasonic energy use after femtosec- ond treatment, coupled with reducing the amount of time you have instrumentation in the eye, has been shown to reduce endothelial cell loss. This is especially important for eyes with Fuchs' endothelial dys- trophy, eyes with shallow chambers, and pseudoexfoliation with or with- out lax zonules. 2 The latter often have endothelial cell abnormalities as well. In all of these patients with underlying issues, the use of a fem- tosecond laser to perform some of the steps with little manual manipu- lation helps provide protection for the endothelium. Occasionally, patients may have a low endothelial cell count without guttata, and there- fore the condition is unknown to the op- erating surgeon. If the LenSx Laser has been utilized prior to cataract surgery, we know we are sparing the en- dothelium to the best of our ability, and patients are at reduced risk of de- veloping post-op corneal edema. The LenSx Laser produces a predictable capsu- lorhexis, both in terms of diameter and location, and is capable of making very precise arcuate incisions. The arcu- ate incisions can ei- ther be opened at the time of the phacoemulsifica- tion surgery, or this can be done during the early post-op period depending upon the surgeon's discretion. References 1. Cionni, R. Presented at AAO 2011 Refractive Subspecialty Day, "Comparison of Effective Lens Position and Refractive Outcome: Femtosecond Laser vs. Manual Capsulotomy." 2. Takács, A, Miháltz, K, Kovács, I, Filkorn, T, Kránitz, K, Nagy, Z. Comparative analysis of corneal endothelial cell density after phacoemulsification performed by femtosec- ond laser-assisted and conventional cataract surgery. Presented at ESCRS 2011, Vienna, Austria. Dr. Richard Mackool is medical director, The Mackool Eye Institute, Astoria, N.Y. Dr. R.J. Mackool is assistant medical director, The Mackool Eye Institute. Contact information Richard Mackool: 718-728-3400, mackooleye@aol.com R.J. Mackool: 718-728-3400, richardmackool@aim.com EW Chicago 2012 9 Practical uses of the femtosecond laser for cataract surgery by Richard Mackool, M.D., and R.J. Mackool, M.D. The LenSx Laser Source: Alcon New technologies enhancing patient outcomes Richard Mackool, M.D., and R.J. Mackool, M.D.

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