COMPLICATED CASES

Managing Femtosecond Laser Cataract Complications

Learning curves are to be expected — but with proper preparation, complications can be easily managed.

BY MICHELLE DALTON, ELS, CONTRIBUTING EDITOR

Cataract surgery is one of the safest surgeries performed with one of the highest rates of patient satisfaction, but as with any surgery, complications are possible. The anterior capsulotomy can influence the rate of complications and the resultant refractive outcomes. Femtosecond lasers have only recently been approved for use in cataract surgery, and studies are beginning to show outcomes are at least as successful as those that can be accomplished with manual techniques. With newer software versions being introduced, there is emerging evidence of better wound architecture, with greater precision and accuracy of the anterior capsulotomy.

Like any new device, there is a learning curve, and complications will occur, says Ronald Yeoh, Medical Director, Founding Partner & Senior Consultant Ophthalmic Surgeon at Eye & Retina Surgeons, Camden Medical Centre, Singapore. As surgeons begin to adopt this technology, some complications unique to femtosecond are also being noted. In Singapore, patients or their health insurance pays for the femtosecond component.

Dr. Yeoh has been using the femtosecond laser in cataract surgery for the past 3 years, and has used the Catalys (Abbott Medical Optics), LenSx (Alcon) and Victus (Bausch + Lomb) platforms. Currently, about 30% of his patients opt for femtosecond laser surgery.

A tear in the anterior capsular rim (see arrow) can lead to unintentional aspiration.

Femtosecond Laser Complications

During one of his earlier surgeries, there was no indication of anything unusual, he says. “This was a 65-year-old male, with good dilation, a normal retina and a straightforward NS2+ cataract. I fully expected a straightforward, routine surgery,” he says.

During the phaco portions of the surgery, Dr. Yeoh inadvertently aspirated an unseen capsulorhexis tag, “leading to a large torn crescent of anterior capsular rim being aspirated and an unusual circumferential (rather than radial) extension.”

Critical to the management of this unnoticed capsular tag “was early awareness that the torn anterior capsular rim had been aspirated. The aspirated capsule was freed from the aspiration port of the I/A cannula, the rest of the I/A of cortex was carefully completed and then the crescent of torn capsule removed to round off the continuous curvilinear capsulorhexis (CCC). A single-piece IOL was successfully implanted in the bag,” says Dr. Yeoh.

In this case, the outcome was excellent (final visual acuity of 20/25 unaided), and the patient was satisfied.

Advice and Pearls for Surgeons

Dr. Yeoh offers several pearls for surgeons who might run across an incomplete capsulotomy.

1. First, examine the femtosecond laser CCC carefully before beginning the phaco step. Typically, whether the CCC is complete or incomplete can be ascertained by visual inspection.

2. Where there are uncut areas of the capsule, great care has to be exercised when performing phaco and I/A. Certainly, the aspiration port of the I/A cannula should be positioned beyond the edge of the femtosecond laser CCC to avoid inadvertently snagging an uncut tag, as happened in this case.

3. For those new to the technology, recognizing that the femtosecond laser CCC is suboptimal requires that the phaco procedure is done using lower parameters i.e., surgeons should use lower and safer flow and vacuum settings than normal in doing ‘slow motion’ phaco. (Dr. Yeoh learned this from Robert Osher, MD.)

4. Finally, the posterior extension of an anterior radial or circumferential tear is unlikely if the above points are heeded.

Today’s Technologies

Dr. Yeoh says today’s iterations of the femtosecond laser are much more advanced than the first generation devices, and the rate of an incomplete capsulotomy is “well under 5%,” says Dr. Yeoh. (With earlier versions, tags and bridges occurred in as many as 20% of eyes.) He is quick to point out this particular complication happened during his own learning curve, and he hasn’t had another instance of an incomplete CCC in years.

“This complication happened in the early femtosecond laser cataract surgery days and today, the newest generation femtosecond lasers give almost perfect CCCs every time,” he says. He added that some devices may create the capsulotomy in as little as 1.5 seconds, which significantly decreases the potential for an incomplete capsulotomy.

The more experience a surgeon has with the femtosecond laser, the less likely complications will occur, Dr. Yeoh concludes. ■