Femtosecond laser-assisted cataract surgery in pediatric patients

Application of Femtosecond Laser in Challenging Cataract Cases

Femtosecond laser can provide precise and customized incision of ocular tissue with excellent accuracy and predictability. Thus, femtosecond laser-assisted cataract surgery (FLACS) can theoretically enhance the safety and efficacy of cataract surgery by providing reproducible and reliable clear corneal incision, limbal relaxing incision, anterior capsulotomy, and lens fragmentation. However, thus far, the superiority of the anatomical and visual outcomes of FLACS over those of conventional cataract surgery have been unclear. Nevertheless, studies have indicated that FLACS can potentially be helpful in improving the safety of cataract surgery in challenging situations, such as zonular weakness, preexisting capsular tear, white cataract, shallow anterior chamber, and pediatric cataracts, which may contribute to enhanced visual and anatomical outcomes. In this review, we provide a summary of the application of femtosecond laser in general cataract cases. In addition, we introduce the application of FLACS in the abovementioned challenging situations and discuss the results of studies regarding the safety and outcome of FLACS in these challenging cases.

Pediatric cataract surgery: considerations and updates in diagnosis and management

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of updates in the diagnosis and management of pediatric cataracts, with an emphasis on recent discoveries in the last two years.

RECENT FINDINGS

Pediatric cataracts remain an infrequent but significant disease with vision threatening consequences. Although much of the management has not changed historically, more recent updates, particularly borrowed from adult cataract management, have influenced the field of cataract management in children. Even these studies emphasize that pediatric cataracts are a distinct clinical entity from adult-onset cataracts, and further research is needed to optimize the diagnosis and management of cataracts in childhood.

SUMMARY

This is an overview of the recent advancements in the diagnosis of management of pediatric cataracts, with advancements that originate from the adult cataract surgery field in addition to studies that challenge classical surgical techniques to make cataract surgery safer and to promote amblyopia therapy.

Portable femtosecond laser assisted cataract surgery in a child with bilateral ectopia lentis with microspherophakia

Purpose

The purpose of this case report is to describe the utility of portable femtosecond laser platform in a child with bilateral isolated microspherophakia and ectopia lentis performed under general anesthesia.

Observation

An appropriately sized and well centered capsulotomy with well centered PCIOL could be achieved in both eyes of the patient.

Conclusion & Importance

The advent of mobile femtosecond laser assisted cataract surgery might prove a useful and convenient platform for surgeries in pediatric patients with subluxated cataracts even under general anesthesia. It may circumvent the need for an additional laser suite and reduce surgical time by eliminating the need for patient movement.

Posterior Capsular Outcomes of Pediatric Cataract Surgery With In-The-Bag Intraocular Lens Implantation

AIM

To investigate the change of posterior capsular outcomes of pediatric cataract surgery with primary in-the-bag intraocular lens (IOL) implantation.

METHODS

We conducted a case series of pediatric cataract children who underwent cataract extraction with primary in-the-bag IOL implantation, posterior capsulorhexis or vitrectorhexis, and limited anterior vitrectomy at the Eye Hospital of Wenzhou Medical University between 2016 and 2019. Digital retro-illumination photographs of pediatric eyes were obtained at baseline and 6 months, 12 months, and the last visit postoperatively. Capsular outcomes of the posterior capsular opening area (PCOA) and lens reprolifration area at those time points were compared. Correlations between the PCOA and influential factors, such as age at surgery, axial growth, and follow-up duration, were analyzed. The study was registered at register.clinicaltrials.gov (NCT04803097).

RESULTS

Data of 23 patients (27 eyes) were used in the final analysis. During follow-up, the PCOA enlarged at a rate of 0.29-0.32 mm²/month during the first six months postoperatively and 0.05-0.08 mm²/month over the next 1-2 years. Six months postoperatively, the PCOA enlargement statistically and positively correlated with the follow-up duration and axial growth. The area of lens reprolifration was 0.46 ± 1.00 mm² at six months postoperatively and then remained stable.

CONCLUSION

The PCOA enlarged rapidly within the first six months after the pediatric cataract surgery with primary IOL implantation. Six months postoperatively, the enlargement of PCOA was positively correlated with follow-up duration and axial growth. Posterior capsulorhexis or capsulectomy should be performed with a diameter of 3.0 to 4.0 mm for good visual axis transparency and the protection of in-the-bag IOL.

Study of the efficiency and workflow of femtosecond laser-assisted cataract surgery in a Spanish public hospital

BACKGROUND

To assess the time-efficiency of a designated operating room (OR) workflow in the introduction of femtosecond laser-assisted cataract surgery (FLACS, LenSx, Alcon®). The study was carried out in a public hospital a with high-volume of procedures.

METHODS

We performed this prospective, controlled, surgical intervention study in the ophthalmology department of a Spanish tertiary referral public hospital. A total of 167 eyes were enrolled, including 62 eyes undergoing conventional phacoemulsification surgery. In phase I, patients were assigned either to FLACS-I (n=63) or conventional phacoemulsification surgery (n=62). One surgeon operated the femtosecond laser, and another completed the procedure, while a third performed conventional phacoemulsification. In the second phase (FLACS-II), all the surgeries were FLACS (n=42). One surgeon performed the FLACS procedure, and two different surgeons completed the surgeries in separate ORs. Surgical and turnover times of all the patients were recorded.

RESULTS

Preparation time was statistically significantly lower in FLACS-I and FLACS-II (P<0.001), whereas the duration of the cataract procedure per se was higher in FLACS-II compared to conventional phacoemulsification (P=0.03). Phacoemulsification energy was higher in FLACS-II compared to FLACS-I (P=0.01), whereas laser-related surgical time was lower (P=0.001). Surgical complications and total surgical time showed no statistically significant differences between any of the three groups.

CONCLUSIONS

This study suggests a time-efficient and suitable workflow model for FLACS, considering the specific requirements and restrictions of a fully booked public hospital. Even so, we have shown that the FLACS procedure does not take longer than conventional phacoemulsification when following a detailed plan for OR workflow. In addition, our data reflect an improvement in FLACS surgical times with ongoing experience.

TRIAL REGISTRATION

NCT03931629 (retrospectively registered).

Efficacy of Toric Intraocular Lens and Prevention of Axis Misalignment by Optic Capture in Pediatric Cataract Surgery

PURPOSE

To compare the outcomes of intraocular lens (IOL) implantation using toric (T)-IOL and non-toric (N)-IOL in pediatric cataract patients with astigmatism, and to examine the effect of optic capture (OC) on the axis misalignment (AM) of the T-IOLs.

SETTING

Department of Ophthalmology, Kindai University Hospital, Osaka, Japan.

DESIGN

Interventional, comparative case study.

METHODS

Consecutive pediatric patients implanted with T-IOLs or N-IOLs were retrospectively reviewed. In the T-IOL group, the preoperative and postoperative corrected distance visual acuity (CDVA) and AM were compared in patients with and without OC.

RESULTS

The T-IOL group included 14 eyes of 11 patients, while the N-IOL group included 22 eyes of 15 patients. One year after surgery, the mean ocular cylinder (1.38 ± 0.80 D) was significantly smaller than the average corneal cylinder (3.33 ± 1.24 D) in the T-IOL group (P = .00012, Wilcoxon signed-rank test). The mean preoperative and 1-year postoperative CDVA (logMAR) were 0.57/0.003 (T-IOL) and 0.71/0.09 (N-IOL), respectively. The AM at 1 week and 1 year after surgery was 2.6° ± 3.7° and 4.4° ± 3.1° for the OC group, and 13.3° ± 8.8° and 18.5° ± 14.8°, for the non-OC group, respectively. The AM was significantly smaller in the OC group than that in non-OC group (P = .009, Mann-Whitney U test) at postoperative 1 week.

CONCLUSION

T-IOL implantation is effective in correcting astigmatism in pediatric cataract patients with astigmatism, and the OC technique is likely to achieve lower AM of the T-IOL.

Femtosecond laser - Assisted cataract surgery in pediatric pyramidal anterior polar cataract

PURPOSE

The purpose of this report is to describe the successful utilization of femtosecond laser assisted cataract surgery (FLACS) in a rare case of pyramidal anterior polar cataract in a female child.

OBSERVATIONS

The patient is a 6 years old girl that presented to the cornea clinic with a unilateral pyramidal cataract that was deemed to be visually significant, and therefore required cataract extraction and intraocular lens implantation surgery. FLACS was proposed and mother consented to proceed with the surgery. The femtosecond laser technology enabled precise completion of a central capsulotomy around the protruding pyramidal capsular lesion.

CONCLUSIONS AND IMPORTANCECONCLUSION

Various capsulorhexis techniques have been described and are used in pediatric cataracts including manual, can opener, vitrectorhexis, and laser, but none has become a standard. We propose the use of femtosecond laser for cataract extraction in cases of pediatric pyramidal cataracts, and hereby provide the first case report of such. The laser is a safe method for capsulorhexis construction and offers an additional advantage of intraoperative anterior segment OCT image guidance with visualization of the pyramidal lesion.

Intraocular lens optic capture in pediatric cataract surgery

Posterior capsule opacification (PCO) remains the most common complication of pediatric cataract surgery despite continuous efforts to reduce its incidence. For this reason, pediatric cataract surgeons have expended considerable effort into preventing and mitigating PCO. The intraocular lens (IOL) optic capture technique has been used for the prevention of PCO after pediatric cataract surgery for more than 20y, but there is still no professional consensus. However, recent research has shown encouraging results. The IOL optic capture technique can be performed without anterior vitrectomy to prevent PCO, even in younger children. The type and characteristics of IOLs used for optic capture technique, the location of IOL and the complications of IOL optic capture in children are here reviewed.