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Cataract Surgery: Focus On Advanced Therapeutics | Apr 2010

Cataract Surgery With the LENSAR Femtosecond Laser Platform

The most exciting part of femtosecond cataract surgery is not what we see today, but rather what is on the horizon.

As an innovator in the area of cataract extraction since the late 1980s, I have been involved in the development of phaco technology for many years. Because of this experience, I was asked to become an advisor to LensAR, Inc. (Winter Park, FL), as the company began testing its femtosecond laser technology for cataract surgery.

About 3 months ago, I traveled to Mexico City to perform 14 surgeries with the LensAR, Inc., platform as part of a clinical trial. While there, my colleagues and I experimented with parameters such as algorithms for softening the nucleus, and we sought to determine the appropriate amount of pressure for docking the laser. Although, in the clinical trial, the procedure progressed differently from how it will when the platform is commercially available, we nevertheless found the laser to be amazing. The eyes we treated had everything from soft to hard nuclei, and in each, we performed a capsulorhexis and were able to soften the nucleus.

The LensAR, Inc., platform employs optical coherence tomography in its integrated design, and the laser docks to the cornea using much less pressure than the IntraLase FS laser (Abbott Medical Optics Inc., Santa Ana, CA), which is a plus for elderly patients. With information obtained from the laser’s anterior segment visualization system, we were able to set the device for the desired depth and width of treatment. The platform allowed us to cut the lens fibrils in any pattern. Because the optimal size and shape for removal of the nuclear particulates is not known, we experimented with cubes and spheres of different size.

It is hoped that the femtosecond laser will dramatically reduce the need for phaco energy for the removal of most nuclei. I envision that most soft-to-moderately dense cataracts will be treated with the laser platform and aspirated using a 0.5-mm I/A or phaco I/A tip. In this scenario, the phaco machine would be used to augment aspiration of the lens material. For hard cataracts, phaco energy will still be necessary.

Although phacoemulsification is a wonderful and safe procedure, any time the surgeon can avoid having an ultrasonic probe in the anterior chamber, he or she is eliminating its potentially adverse effects on the blood-aqueous barrier, endothelium, and trabecular meshwork. Without the use of ultrasound during cataract extraction, the eye’s environment is safer, and there is no risk of tearing the posterior capsule with a phaco tip. Femtosecond laser cataract surgery will also be associated with less unexpected vitreous loss and reduced damage to the iris from high-powered interfaces.

Surgeons are getting better and better at creating quality capsulorhexes. The LensAR Laser System, however, allows the ophthalmologist to better control the location of the capsulorhexis as well. A multifocal IOL, for example, should be centered on the visual axis, which is very difficult to find during surgery. The femtosecond laser allows the surgeon to identify and create the capsulorhexis around the visual axis. When the implant is centered in the capsulorhexis, it will therefore also be centered on the visual axis.

The size of the capsulorhexis is important for successful cataract extraction. The capsulorhexis must overlap the IOL by 0.25 mm, which can be achieved perfectly in every case with the laser.

Other advantages of femtosecond cataract surgery are that patients love the idea of lasers and femtosecond cataract surgery has applicability for all ophthalmologists. All cataract surgeons will benefit from improved procedural reproducibility and better capsulorhexes, easier removal of nuclei, and decreased surgical times. High-volume surgeons will be able to perform many tasks simultaneously with the LensAR, Inc., platform; they will be able to swing the laser into place for the several steps of the cataract procedure and then move it out of the way so that they may remove the cataract. In this setting, I envision phacoemulsification’s taking on a new role, and surgeons may start to think of the cataract procedure as a “femto-phaco” procedure.

I believe femtosecond laser cataract surgery has real potential. My vision is that a physician will sit down to perform cataract surgery, the patient will be brought into the room, and the femtosecond laser will be put into position. Before it is docked, the laser will perform a corneal topographical and wavefront analysis. It will find the visual axis and place registration marks. Then, the surgeon will program the refractive goal into the system. The laser will analyze this input and determine an algorithm for the nuclear treatment. It will then perform a “demolition” by cutting the nucleus into the size and shape selected. Next, it can make the capsulorhexis around the visual axis, create limbal relaxing incisions for the treatment of preexisting astigmatism, and perform a paracentesis wherever the surgeon desires. The LensAR Laser System can even make a locking incision which is guaranteed to be watertight as well as correct for the induced cylinder.

William J. Fishkind, MD, is the co-director of Fishkind and Bakewell Eye Care and Surgery Center in Tucson, Arizona, and he is a clinical professor of ophthalmology at the University of Utah in Salt Lake City. He is a consultant to LensAR, Inc. Dr. Fishkind may be reached at (520) 293-6740; wfishkind@earthlink.net.

For video of the procedure: http://eyetube.net/v.asp?minime

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