Laser Cataract Surgery

May 17, 2011Los Angeles Cataract Surgeon 65 Comments »

Laser Cataract Surgery

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The following article was written by Dr. Stephen Slade:

How the LenSx® laser, and laser refractive cataract surgery, impacts the Ophthalmic practice.

In October 2010, LenSx laser (Alcon Laboratories, Inc., Fort Worth, TX) became the first femtosecond laser to receive FDA 510k clearances to perform all four major steps of laser cataract surgery, anterior capsulotomy, laser phacofragmentation, and single-plane and multi-plane arcuate corneal incisions at the time of cataract surgery. This timetable is wrong, they received the approvals over time, with the first one at the start of 2010. With the launch of this revolutionary technology, the ophthalmic community is watching the LenSx laser as it ushers in the era of laser refractive cataract surgery.

PROPRIETARY Optical Coherence Topography (OCT) IMAGING

The LenSx laser features proprietary, real-time OCT technology that enables surgeons to view and identify key landmarks in the anterior chamber and on the cornea. The OCT technology allows for image-guided precision of the laser, as it replaces many of the manual steps in traditional cataract surgery.

BETTER REFRACTIVE OUTCOMES

With OCT-guided femtosecond laser technology, cataract surgeons hope to be able to improve the refractive outcomes of patients who desire this goal in addition to the removal of their cataract. Those familiar with the femtosecond technology believe it can deliver higher-quality results by increasing the precision and reproducibility of several of the manual steps in traditional cataract surgery (corneal incisions, the capsulotomy, and nuclear fragmentation, among others still under investigation). As I stated in a recent article about this technology, I believe the LenSx laser will offer cataract patients improved UCVA as a result of reduced astigmatism and an ability to control induced spherical error.”1 The laser is able to reproducibly perform the anterior capsulotomy to the surgeon’s specified size and make precise arcuate incisions in the cornea, both of which may help the surgeon achieve the patient’s refractive goal.

GREATER SAFETY

With increased surgical reproducibility comes greater safety. Many cataract surgeons have referred to the continuous curvilinear capsulorhexis as perhaps the most difficult step of cataract surgery, but also one of the most important, because its overlap of the IOL’s optic is critical to the prevention of posterior capsular opacification.2,3 Because the manual capsulotomy results in a high variability of diameter and centration, standardization of this step can have a positive impact on surgical safety, particularly in compromised eyes such as those with pseudoexfoliation, weak zonules, traumatic cataracts, etc. I have achieved a 100% diametric accuracy of ±0.25 mm with the LenSx laser. with only 18% of manual capsulotomies achieving this goal. Furthermore, the femtosecond ablation leaves such a smooth edge to the capsulotomy that it reduces the risk of a capsular tear.4

Precise corneal incisions and lens fragmentation have their respective advantages as well. Like all of the laser’s functions, the surgeon is able to adjust and preprogram the size and location of the LenSx’ corneal incisions for total control. These wounds are smooth and self-sealing, leading to a likely reduced risk of infection such as endophthalmitis.

Lens fragmentation with the LenSx laser is successful with the hardest lenses able to be cracked although white cataracts will not be able to be treated. [Dr. Slade: what has been your experience?], in my experience. Published results from the laser’s early clinical trials were impressive. The investigators were able to significantly reduce the average phaco power compared with a traditional, manual phaco technique.5-7 As we cataract surgeons know, the ability to use less ultrasonic energy directly correlates with less endothelial cell loss. There also seem to be direct benefits for patients with low cell counts, traumatic cataracts, and other complex cases. [Dr. Slade: please add any additional clinical benefits based on your experience]

BUILDIING THE PRACTICE

The LenSx femtosecond laser not only offers benefits for patients, but it is likely to grow the practice as well. The refractive nature of the LenSx procedure makes it a patient-billed, noncovered service. I predict that, just as refractive patients have come to show a preference for all-laser LASIK, cataract patients will appreciate the greater safety and improved refractive outcomes related to laser refractive cataract surgery. Those who elect an enhanced refractive outcome will be impressed by the options this technology will give them. I expect laser refractive cataract procedures to be a win-win for surgeons and their patients.

  1. Slade SG, Culbertson WW, Kreuger RR. Femtosecond lasers for refractive cataract surgery. Cataract & Refractive Surgery Today. 2010;10(8): 67-69.
  2. Aykan U, Bilge AH, Karadayi K. The effect of capsulorhexis size on development of posterior capsule opacification: small (4.5 to 5.0mm) versus large (6.0 to 7.0mm). Eur J Ophthalmol. 2003;13:541-545.
  3. Hollick EJ, Spalton DJ, Meacock WR. The effect of capsulorhexis size on posterior capsular opacification: one-year results of a randomized prospective trial. Am J Ophthalmol. 1999;128:271-279.
  4. Nagy, Z. Intraocular femtosecond laser applications in cataract surgery: precise laser incisions may enable surgeons to deliver more reproducible outcomes. Cataract & Refractive Surgery Today. 2009;9(9):29-30.
  5. Nagy, Z. Use of the femtosecond laser in cataract surgery. Paper presented at: The AAO annual meeting; October 27, 2009; San Francisco, CA.
  6. Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg.2009;25(12):1053-1060.
  7. Nagy Z. Use of femtosecond laser system in cataract surgery. Paper presented at: The XXVII Congress of the ESCRS; September 15, 2009; Barcelona, Spain.

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Posted on May 17, 2011 at 9:35 pm
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