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6 Tailored treatment When I examine a patient at the slit lamp, I determine whether the lens is dense or soft. If the lens is dense, I plan for 4-quadrant segmentation and softening, typically choosing a 350-µm grid. If the lens is very soft, I soften the lens using a larger 600-µm grid, skip the segmentation, and use a supracapsular technique. We sometimes encounter special situations. If the patient has a dense lens and small pupil, I skip the femtosecond capsulotomy and proceed with the lens segmentation and softening. With small pupil cases, I prefer to perform a manual capsulotomy instead of limiting myself to a tiny femto capsulotomy. Having the lens already fragmented in these dense nuclei still affords me the lens-softening benefits. If the patient has a posterior polar cataract, I perform capsulotomy with- out fragmentation. A small case series showed a higher complication rate with the laser, likely due to the femtosecond- induced plasma bubbles creating pressure against the existing posterior capsule defect. 4 We have been moving from ultra- sound-driven lens removal to fluidics- driven lens removal, and femtosecond lens softening accelerates that trend. I use the Catalys and Whitestar Signature Phacoemulsification System (Abbott Medical Optics), which includes a dual pump, allowing me to switch pumps within each case: The peristaltic system holds large fragments at the tip (during initial "chopping" of presegmented nu- clei), and the venturi pump draws small fragments to the tip (Figures 1 and 2). With a soft lens, I proceed directly to venturi fluidics and perform a femto- flip. It's a very efficient way to remove the lens safely. I have found that by laser fragmenting the cataracts (lens softening), even medium density lenses can be femto-flipped easily and safely while maintaining corneal clarity. This is especially true with the followability of venturi fluidics. Conclusion Using the femtosecond laser and a dual pump phacoemulsification unit, we can tailor lens fragmentation to the spe- cific cataract density and type. I plan whether to segment, soften, or perform both, and then I chose whether to use venturi fluidics alone or a combination of peristaltic and venturi with the Ellips FX Technology (Abbott Medical Optics). This provides a customized solution for all cataract types. With these two tech- nologies, I believe we have achieved the highest level of safety. References 1. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Effect of femtosecond laser fragmentation on effective phacoemulsification time in cataract surgery. J Refract Surg. 2012; 28:879–883. 2. Conrad-Hengerer I, Al Juburi M, Schultz T, Hen- gerer FH, Dick HB. Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser-assisted cataract surgery: three- month follow-up. J Cataract Refract Surg. 2013; 39:1307–1313. 3. Abell RG, Allen PL, Vote BJ. Anterior chamber flare after femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2013; 39:1321–1326. 4. Alder BD, Donaldson KE. Comparison of 2 techniques for managing posterior polar cataracts: Traditional phacoemulsification versus femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2014; 40:2148–2151. continued from page 5 Figure 2. Fluidics settings by intraoperative step "Using the femtosecond laser and a dual pump phacoemulsification unit, we can tailor lens fragmentation to the specific cataract density and type. "

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