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4 measure the thickness of the periph- eral cornea and set our AK knife to 80%, 90%, or the desired depth. With the LenSx Laser, surgeons have the ability to visualize the corneal profile and customize and program the ar- cuate incision(s) to their preference. For my cases, when using LenSx to cut arcuate incisions, I typically use the default depth (80%), optical zone (9 mm), and angle of incidence (90 degrees). However, I input my keratometry readings into an LRI calculator (www.lricalculator.com) to determine the length of my arcu- ate incisions and use the following personalized nomogram in order to account for the smaller optical zone (as the LRI calculator assumes that the arcuate incisions are being placed at the corneal limbus): 70% of the arc length for with-the-rule astigmatism, 80% of the arc length the overall design of the new unit (that comes with an additional high resolution monitor), all of which are designed to integrate more harmoni- ously with the other components of the cataract and refractive suite. Another important aspect of being a full-time faculty member at an academic institution is the em- phasis we place on teaching the next generation of cataract surgeons. We have residents and fellows who are actively involved in our cataract pro- cedures, and they have the fortunate opportunity to witness firsthand and participate in the latest technology that's being used for modern day cataract surgery, which certainly includes FLACS. Our staff have also taken an integral role in managing and operating the femtosecond laser and other components of our cataract and refractive suite. One crucial component of a successful FLACS program includes regular and timely hardware and software up- grades, which ensure that important feedback from surgeon users is con- stantly incorporated to improve the performance and functionality of the femtosecond laser. Another critical component that is oftentimes under recognized is the clinical and service support team of clinical application specialists and field service engi- neers who ensure that the femtosec- ond laser is operating at the highest level. With all of these components in place, I am reassured that we are offering our patients access to the most advanced technology in an ef- fort to maximize outcomes with our cataract/refractive procedures. Contact information Kim: terry.kim@duke.edu for oblique astigmatism, and 100% of the arc length for against-the-rule astigmatism (with a maximum limit of a 60-degree cut). The last aspect of the femtosec- ond laser technology is the primary and secondary corneal incision. I am excited about the latest LenSx Laser software that will improve the placement of the primary and secondary incisions. This new soft- ware will provide a yellow margin alignment marker line that will serve as a more accurate reference point as well as enhanced visualization of the anatomic landmarks to help improve the physical alignment of the primary incision. Additional enhancements include a modified range for secondary entry incision angle (30–90 degrees). I'm excited about the enhanced graphic user interface, intuitive buttonology, and continued from page 3 Intraoperative planning with the LenSx Laser by Cathleen McCabe, MD I n my multispecialty practice with a two operating room am- bulatory surgery center (ASC), we have been able to position our LenSx Laser (Alcon, Fort Worth, Texas) as a third room that has access to both ORs. In 2012, when we were choosing a laser for our ASC, we analyzed what the different platforms could offer our practice. There were many factors in- volved in our decision. We wanted accessibility to other surgeons who had significant experience with the laser. We wanted a platform that was placed widely throughout the nation and the world. Additionally, we preferred a detached bed be- cause we thought that would facil- itate flow and make the procedure easier and seamless for our pa- tients, many of whom have ambu- latory issues. We liked the flexibility of the LenSx Laser platform. We also appreciated the vari- able beam profile, which is used not just for nuclear disassembly and capsular treatment with a capsulotomy, but also for corneal procedures that we were currently performing, such as cataract sur- gery incisions and arcuate incisions. Additionally, the laser could be used for corneal indications that might come along in the future. Two more corneal functions, pockets and tun- nels, are launching at this meeting as a side cut-only function to the flap-making software. Another feature of the LenSx Laser is the live OCT. We are able to image all of the tissues in the eye— not just a reconstructed image, but an actual OCT image of what is going on in the eye at that moment. This is reassuring to me because there are several different factors that we need to analyze well during surgery. For example, it is nice to know the thickness of the lens and the depth of the anterior chamber with a visualized image that I have taken just before taking the patient into the OR (Figure 1). I have been impressed by how important this is in surgical planning. I recently saw a patient with a dense white cortical cataract. I find these cases to be much easier with a femtosecond laser. This particular patient had a very thin cataract, which is not something we can appreciate as we start a procedure because we don't have visualization of the posterior capsule (Figure 2). It is easy to misjudge these cases and think that the nucleus is much thick- er than it is and potentially even penetrate through the nucleus and the posterior capsule. In cases like this, understanding the anatomy prior to surgery helps me to better plan the procedure and avoid other complications. Another example would be a posterior polar cataract, where I can see the defect in the posterior cap- sule prior to surgery. Still another is a decentered lens that would be an indication of zonular pathology. In all of these cases, having a high quality live image of the OCT helps with intraoperative planning and the avoidance of complications. When choosing a femtosecond laser, the variable beam profile was one of the features that we thought was a big advantage with this plat- form. The energy is optimized to the tissue that is being treated, so the beam profile in the cornea lends itself to precise and reproducible primary and secondary incisions, as well as the arcuate incisions. The profile changes for capsulotomy and efficient capsulorhexis. Even in cases with fibrosis of the capsule, I've seen complete capsulotomies a high percentage of the time. Nuclear disassembly is efficiently achieved with the appropriate pro- file for the nucleus. An adaptable system is the best of all worlds. One laser has multiple beams perform- ing optimally in the appropriate tissue. The LenSx Laser also has a flap-making capability, and this has allowed us to achieve high quality flaps. The bed is smooth, and the flaps are reproducible. It is a comfortable treatment for the patient, and the docking is easy and intuitive. Additionally, it is fast, and because we can have it adjacent to our already existing excimer laser, we are able to use our space effi- ciently and provide more services to our patients in one location. I am excited about the fact that the newest upgrade will provide the ability to create tunnels in the cornea and create pockets. As we expand the indications for corneal procedures, it will help our patients with other refractive procedures, other therapeutic treatments for complex corneal disease, and pres- byopia correction in the future. One of the strengths of this platform is the adaptability and the ability to continue to present new treatment options in the future that will allow us to help our patients. Figure 1. Thick lens Source: Cathleen McCabe, MD continued on page 5 Innovations in cataract and refractive surgery Please refer to pages 7 and 8 for Important Product Information about the Alcon products described in this supplement.

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