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cell loss, lower increase of corneal thickness at the incision site, and better tunnel morphology compared to the manual technique. 2 The study included 60 eyes: 30 that underwent femtosecond laser clear corneal incisions and 30 that under- went manual clear corneal incisions. Central endothelial cell count was significantly higher in the femtosecond laser group compared to the manual group at 7 and 30 days postoperative- ly. Total phaco time was significantly lower in the femtosec- ond laser group. The LenSx Laser also offers multiple lens fragmentation pattern options. I use a grid pattern, which is composed of tiny cubes. The surgeon can determine the exact size of the cube shapes, and I have gotten used to cube shapes around 275 µm to 300 µm. I find that this size cube will go down the lumen of the phaco port without needing much energy. The femtosecond laser is prechopping the lens into these tiny cubes, but I focus the energy more on the densest part of the cataract, the central 4–4.5 mm. I do not put as much energy outside of this area; I haven't found it to be necessary. The LenSx Laser reduces the need for phaco energy and femto energy, and it simplifies the entire procedure. It decreases procedure time, and I am consistently in the low single digits with CDE power. In my practice, I have two OR setups, and the laser is in a separate third room. I find this to be very efficient, as I rotate between the rooms with typically no downtime between patients. Refractive outcomes Laser refractive cataract surgery with a femtosecond laser has been shown to improve predictability of IOL power calcula- tion over conventional phacoemulsification surgery. 3 A recent study prospectively evaluated 77 eyes from 77 patients who underwent laser refractive cataract surgery and 57 eyes from 57 patients who underwent conventional cataract surgery. No significant differences were found between the groups with regard to age, axial length, keratometry, and preoperative corrected visual acuity. At least 6 weeks after surgery, mean absolute error was significantly lower in the LenSx Laser group than in the conventional group. The difference was the great- est in short (axial length <22.0 mm) and long (axial length >26.0 mm) eyes. Additionally, a separate study found that a continuous curvilinear capsulorhexis created with the LenSx Laser resulted in a more stable refractive result and less IOL tilt and decentra- tion than a manual continuous curvilinear capsulorhexis. 4 In this prospective, randomized study, 20 eyes had a continuous curvilinear capsulorhexis created by the LenSx Laser, while 25 eyes had a continuous curvilinear capsulorhexis created man- ually. The study found that horizontal and vertical tilt were significantly higher in the manual continuous curvilinear capsulorhexis group, and lenses implanted after manual con- tinuous curvilinear capsulorhexis had greater horizontal and total decentration. The researchers noted significant differenc- es in the homogeneity of dichotomized IOL vertical tilt and both horizontal and total decentration distribution. Total IOL decentration was found to have a significant correlation with changes in manifest refraction values between 1 month and 1 year after surgery, and a significant correlation was observed between IOL vertical tilt and corrected distance visual acuity. Difficult cases The LenSx Laser is especially beneficial in difficult cases. I have used it on a few eyes with anterior lenticonus, and it has worked very well. Additionally, I have used it on a couple of eyes with posterior lenticonus, and that has worked out great. It has also been terrific in treating eyes with traumatic cataract where we have had ruptured anterior lens capsules and white mature cataracts for the capsulotomy. These are the types of challenging cases where I think the LenSx Laser has really helped. In virtually all of those cases, it wasn't done from a refractive standpoint but what we felt was in the best interest of the patient. I have been thrilled with its consistency and reproducibil- ity, and I think it has been wonderful overall. References 1. Mayer WJ, Klaproth OK, Hengerer F, Kohnen T. Impact of crystalline lens opacification on effective phacoemulsification time in femtosecond laser-as- sisted cataract surgery. Am J Ophthalmol. 2014;157(2):426–432. Figures reprinted with permission from Elsevier. 2. Mastropasqua L, Toto L, Mastropasqua A, et al. Femtosecond laser versus manual clear corneal incision in cataract surgery. J Refract Surg. 2014;30(1):27–33. 3. Filkorn T, Kovacs I, Takacs A, Horvath E, Knorz MC, Nagy ZZ. Comparison of IOL power calculation and refractive outcome after laser refractive cataract surgery with a femtosecond laser versus conventional phacoemulsification. J Refract Surg. 2012;28(8):540–544. 4. Kranitz K, Mihaltz K, Sandor GL, Takacs A, Knorz MC, Nagy ZZ. Intraocular lens tilt and decentration measured by Scheimpflug camera following manual or femtosecond laser-created continuous circular capsulotomy. J Refract Surg. 2012;28(4):259–263. With multiple fragmentation patterns and combinations available, the LenSx Laser provides greater flexibility to fit more patient anatomies and surgeon preferences. Dr. Solomon is in practice in Charleston, S.C. He can be contacted at kerrysolomon@me.com. Kerry Solomon, MD 5

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