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Cover Focus | Apr 2015

Femtosecond Lasers in Complex Cataract Surgery

Treating nystagmus and a mature cataract.

An optician with a career spanning more than 30 years was referred to my practice by his ophthalmologist. The patient had a mature white cataract and associated nystagmus with corneal astigmatism in his right eye. Because I always try to maximize the vision endpoint of any eye surgery, in keeping with my “corneoplastique” principals, I try to harness every technology to the patient’s advantage.1-3 When treating a mature white cataract, the most precarious surgical step is creating the capsulorhexis, which in a split second, can lead to the Argentinian flag sign (capsular tear typically possible in white cataracts), which could mean the end of that patient’s 20/20 potential.


Given we surgeons’ prior experience of successfully creating capsulorhexes manually, we could question the advantage of femtosecond laser technology. If we had even one capsulorhexis in a white cataract that resulted in the Argentinian flag sign, or if we did have a capsulorhexis, which although circular could be decentered given the dynamics of such an eye, and then again, even if we had a well-centered, circular capsulorhexis, what if the size was inadvertently too small to bring out these big pieces of hard cataract that could inherently lead to tears during the surgery again jeopardizing the planned outcome eventually? Now add to that the difficulty level of a constantly moving eye while we are creating the capsulorhexis (eg, nystagmus) as in this case, and femtosecond laserassisted surgery quickly becomes a necessity on our wish list.


The availability of femtosecond laser technology today underscores the importance of discussing this technology with patients, particularly with a mature white cataract, subluxated or dislocated cataracts, pseudoexfoliation, or associated uncontrolled eye movements, as the patient in this case.4-6

For this patient, I used the femtosecond laser not only to enable a consistent, central, circular, and predictably sized capsulorhexis in this mature white cataract but also to stabilize and control the eye by docking while performing the capsulorhexis to negate the effects of constant nystagmus (Figure).


Fortunately, the surgery turned out well. The result was a well-predicted capsulorhexis in size and centration that enabled the rest of the procedure’s steps to be completed flawlessly while I controlled the eye movements with my second instrument and worked in the patient’s null-point position.

Although the femtosecond laser can surely be used for premium cataract surgery cases,7-9 I believe that in cases such as this one and other complex cataract surgical scenarios that I have described in previous publications, a discussion with the patient regarding its advantage could be mandatory in aiming for vision outcomes of emmetropia despite the complexity of the case and its associated pathologies.n

1. Gulani AC. Evaluating the impact of femto laser-assisted capsulotomy. Cataract & Refractive Surgery Today Europe. 2014;9(2):36-50.

2. Gulani AC. Shaping the future and reshaping the past: the art of vision surgery. In: Copeland and Afshari’s Principles and Practice of Cornea. New Delhi, India: Jaypee Brothers Medical Publishers; 2013;2:1252-1273.

3. Donnenfeld E, Gulani AC. Astigmatism correction during cataract surgery. In: Garg H, Alió JL, eds. Femtosecond Laser: Techniques and Technology. 1st ed. Miami, FL; Jaypee Highlights Medical Publishers. 2012;21:155-161.

4. Gulani AC. Femtosecond lasers: are they becoming a necessity in cataract surgery? Cataract & Refractive Surgery Today. November/December 2013;13(11):25-26. http://crstoday.com/2013/12/femtosecond-lasersare- they-becoming-a-necessity. Accessed April 2, 2015.

5. Gulani AC, Wang M. Femtosecond laser in ophthalmology: past, present and future. In: Garg H, Alió JL, eds. Textbook of Femtosecond Laser: Technology & Techniques. 1st ed. Miami, FL; Jaypee Highlights Medical Publishers; 2012;22:162-164.

6. Gulani AC. Femtosecond laser in cataract surgery: designer cataract surgery. In: Garg H, Alió JL, eds. Femtosecond Laser: Techniques and Technology. 1st ed. Miami, FL; Jaypee Highlights Medical Publishers; 2012:152-154.

7. Reddy KP, Kandulla J, Auffarth GU. Effectiveness and safety of femtosecond laser-assisted lens fragmentation and anterior capsulotomy versus the manual technique in cataract surgery. J Cataract Refract Surg. 2013;39(9):1297-1306.

8. Dick HB, Canto AP, Culbertson WW, Schultz T. Femtosecond laser-assisted technique for performing bag-inthe- lens intraocular lens implantation. J Cataract Refract Surg. 2013;39(9):1286-1290.

9. Kohnen T. Evolution of femtosecond-laser technology for lens-based surgery-continued. J Cataract Refract Surg. 2013;39(9):1285.

Arun C. Gulani, MD, MS
• founding director and chief surgeon of the Gulani Vision Institute in Jacksonville, Florida
• (904) 296-7393; gulanivision@gulani.com

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