Eyeworld Supplements

3 LenSx Laser technology for routine and complex cataract cases by Terry Kim, MD A s a cornea specialist and cataract surgeon at an academic institution, it has been exciting to have the latest technology in cataract surgery at our disposal. The LenSx Laser (Alcon, Fort Worth, Texas) is one example of this technology that has proven to be a safe and effective option that we offer to our cataract patients. A high percentage of my pa- tients now choose the LenSx Laser for their cataract surgery, which is an elective decision that comes with an out-of-pocket cost, and that percentage continues to grow. The LenSx Laser offers higher precision and minimizes some of the safety concerns seen with manual proce- dures, and patients easily under- stand the benefits of laser technolo- gy in cataract surgery with minimal chair time and explanation. As a result, they have been receptive and motivated to proceed with femtosec- ond laser-assisted cataract surgery (FLACS). Capsulotomy in routine and complex cases The LenSx Laser complements my cataract procedure well from numerous standpoints. For exam- ple, more than 99% of the time, I achieve a complete capsulotomy. It's invaluable in routine cases, where it helps to ensure the position of the intraocular lens, and this is extreme- ly relevant to advanced technology lenses. The LenSx Laser ensures that I have a consistently sized, shaped, and centered capsulotomy, with pre- dictable overlap of the anterior cap- sule over the IOL optic edge, which contributes to optimal IOL centration and stability long term. It is also helpful in complex cas- es, such as mature white cataracts. In my experience, these cases are unpredictable when the capsuloto- my is performed manually. Despite the use of an ophthalmic viscoelas- tic device and trypan blue staining, intracapsular pressure frequently leads to extension of the anterior capsule opening and the well-de- scribed Argentinian flag sign, which increases the risk for intraoperative complications, including posterior capsular extension, vitreous loss, posterior lens dislocation into the retina, and complex IOL manage- ment. For these scenarios in partic- ular, it is advantageous to have the capsulotomy performed in a closed anterior chamber setting to mini- mize these complications and ensure a successful anatomic and visual outcome (Figure 1a and b). Lens fragmentation Another underappreciated and overlooked benefit of FLACS with the LenSx Laser is the lens fragmen- tation portion of the procedure. I see a lot of dense cataracts in my practice, and I have a specific lens fragmentation pattern for these cases that makes the phacoemul- sification portion of the procedure more predictable and controlled. I am a chop surgeon, and before using the LenSx Laser, I was using a horizontal chopper that required passing the chopper underneath the anterior capsule and around the lens equator while immobilizing the lens with my phaco handpiece. Many sur- geons are not comfortable with this maneuver. Now, thanks to the FLACS lens fragmentation pattern, I am per- forming my horizontal chop proce- dure in the central nucleus with the phaco handpiece to immobilize the lens and a Nichamin-style chopper to perform a quick horizontal chop without having to pass the chopping instrument blindly under the ante- rior capsule. Others may opt to do a vertical chop here, but the same principle applies, whereby the need for passing a second instrument pe- ripherally and/or blindly is eliminat- ed, and instead the second chopping instrument is kept in the middle of the nucleus where it is clearly visible and undoubtedly safer. This ap- proach also helps with the extremely dense lens that is typically accom- panied by a leathery posterior plate that makes it difficult to completely fracture no matter what technique is being used. By employing these lens fragmentation patterns, where I use three radial lines in a spoke pattern to fragment the dense lens into six pie-shaped pieces (Figure 2), I can use my chopping maneuver to then fracture the dense nucleus (even those with leathery posterior plates) along these fragmentation planes completely in a predictable manner, which reduces the use of ultrasound energy and phaco time as well as the overall struggle of managing the flexible posterior lens fibers. Incisions Another area where the LenSx Laser makes a difference is with arcuate incisions. When targeting a specific visual outcome in cataract surgery, whenever possible I target em- metropia and plan to address any and all factors that could impact my planned correction target. This includes evaluating preop astigma- tism, SIA, and the potential for re- sidual astigmatism that may hamper full refractive correction. We have all been performing limbal relaxing and astigmatic keratotomy incisions manually as part of cataract surgery for a long time, and their utilization has certainly increased with the arrival of presbyopia-correcting IOLs in an effort to help manage resid- ual astigmatism that can impact the visual outcomes with multifocal IOLs. Anything we can do to improve the accuracy and predictability when creating these incisions is welcome, and I think that arcuate incisions performed with the femtosecond laser offer a higher level of precision than even I can achieve using an AK knife. We know from the high defi- nition OCT image of the cornea that we can program the architecture of these incisions more accurately in terms of their depth, optical zone, and angle of incidence. Most of us typically do not use a pachymeter to continued on page 4 Figure 1a: LenSx Laser capsulotomy for mature white cataract Figure 1b: Free floating capsulotomy stained with trypan blue Figure 2: LenSx Laser lens fragmentation pattern for dense lens Source (all): Terry Kim, MD

• Cover