Prostaglandin release during femtosecond laser-assisted cataract surgery: main inducer

Update on Femtosecond Laser-Assisted Cataract Surgery: A Review

The advent of femtosecond lasers has resulted in a new standard in cataract surgery, intended to overmatch the paradigm of conventional phacoemulsification. Femtosecond laser-assisted cataract surgery (FLACS) enables a higher level of reproducibility, precision, accuracy, and customization when performing several steps of cataract (or lens) surgery. Capsulotomy, corneal incisions, lens fragmentation, and arcuate incisions are the main procedures performed using FLACS. As the demand for better refractive outcomes and spectacle independence increases, the features of FLACS are highly relevant, especially when considering the implantation of premium intraocular lenses, such as toric, enhanced depth-of-focus, or multifocal lenses. The present article reviews the state of the art of femtosecond laser-assisted cataract (lens) surgery, contemplating the advantages and limitations of the two types of femtosecond laser pulses available (high and low energy) by evaluating their reported outcomes and complications.

Anterior chamber cytokine production and postoperative macular edema in patients with diabetes undergoing FLACS

PURPOSE

To evaluate the effect of femtosecond laser-assisted cataract surgery (FLACS) and manual cataract surgery (MCS) on proinflammatory cytokine expression in patients with diabetes vs nondiabetic patients.

SETTING

Outpatient surgical center in Vaughan, Ontario, Canada.

DESIGN

Prospective cohort study.

METHODS

Patients with diabetes and nondiabetic patients undergoing noncomplicated MCS or FLACS were assigned into 4 cohorts: MCS nondiabetic (n = 30), FLACS nondiabetic (n = 42), MCS diabetic (n = 40), and FLACS diabetic (n = 40). Aqueous humor inflammatory mediator concentrations were evaluated at MCS onset and after femtosecond laser treatment. The presence of cystoid macular edema, anterior chamber (AC) inflammation, central retinal thickness, macular volume, and retinal microvascular changes (through optical coherence tomography angiography) were evaluated preoperatively and on postoperative day 1, week 1, month 1 (POM1), and month 3 (POM3).

RESULTS

Patients with diabetes receiving FLACS had a higher concentration of interleukin (IL)-7, IL-13, and interferon-induced protein-10 than MCS diabetic patients; they also demonstrated higher levels of vascular endothelial growth factor and lower levels of interferon (IFN)-γ, granulocyte colony-stimulating factor, and IFN-α2 compared with MCS nondiabetic patients. Macular volume appeared to be significantly higher in MCS diabetic vs MCS non-diabetic patients at POM1 and between FLACS diabetic vs FLACS nondiabetic patients at POM3. There were no other significant differences between the cohorts for any parameter.

CONCLUSIONS

FLACS use in patients with diabetes demonstrated some differences in AC cytokine expression compared with non-diabetic FLACS or diabetic patients undergoing MCS; however, there was no increase in clinical inflammatory biomarkers. FLACS seems to be a safe technique to use in patients with diabetes.

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.

Changes of Subjective Symptoms and Tear Film Biomarkers Following Lenticule Extraction

PURPOSE

To investigate the influence of lenticule extraction on subjective symptoms and objective biomarkers of dry eye and to clarify relationships between markers and find indicators for subjective symptoms after lenticule extraction.

METHODS

Right eyes of myopic patients undergoing lenticule extraction surgery (n = 35) were examined preoperatively and 5 and 90 days postoperatively using established clinical dry eye examination methods (tear film break-up time [BUT], Schirmer test, lissamine green and fluorescein staining, and Ocular Surface Disease Index (OSDI) questionnaire). A patient subset was also examined after 1 year (n = 14). Tear samples were eluted from Schirmer strips and then measured with enzyme-linked immunosorbent assays (calcitonin gene-related peptide (CGRP), interleukin-1β, IL-6, IL-8, matrix metallopeptidase 9 [MMP-9], nerve growth factor, and tumor necrosis factor-α). Postoperatively, unpreserved ofloxacin and dexamethasone eye drops were given (four times a day for 10 days).

RESULTS

BUT decreased at days 5 (P = .023) and 90 (P = .025). Lissamine green staining increased at day 90 (P = .036). OSDI values increased at day 5 (total values, vision-related function, ocular symptoms, all P < .001, but not environmental triggers) and at day 90 (vision-related function, P = .017). A downregulation of CGRP (P = .006) and MMP-9 levels (P = .042) was observed on day 5 compared to day 90.

CONCLUSIONS

Due to incongruity of patient symptoms, clinical signs, and tear protein changes, no predictive indicator was found, but some patients reported increased discomfort. Changes after lenticule extraction are not exclusively due to dry eye. [J Refract Surg. 2023;39(9):597-604.].

Safety and efficacy of cataract surgery performed with a low-energy femtosecond laser compared with conventional phacoemulsification in Chinese patients: a randomized clinical trial

BACKGROUND

To compare the safety and efficacy of femtosecond laser-assisted cataract surgery (FLACS) performed with the low-energy FEMTO LDV Z8 (Ziemer Ophthalmic Systems AG, Port, Switzerland) laser compared with conventional phacoemulsification (CP) in Chinese patients.

METHODS

This prospective, multicenter, interventional study included 126 patients who were randomized (1:1) to undergo either FLACS or CP followed by intraocular lens (IOL) implantation between January 2019 and April 2020. The primary endpoint included the comparison of the endothelial cell loss (ECL) between the two groups at 3 months. Secondary endpoints included the comparison of cumulative dissipated energy (CDE), change in central corneal thickness (CCT) from baseline, and postoperative uncorrected and corrected distance visual acuities (UDVA and CDVA) in the two groups.

RESULTS

At all postoperative time points, the FLACS group was found to be non-inferior to CP for the mean ECL (- 409.3 versus - 436.9 cells/mm² at 3 months) and mean CDE (4.1 versus 4.5 percent-seconds). The increase in CCT was significantly lower in the FLACS group compared with the CP group at Day 7 (4.9 versus 9.2 µm; P = 0.04); however, the difference was not statistically significant at 1 and 3 months. Postoperatively, mean UDVA and CDVA were comparable between the two groups. No intraoperative complications occurred.

CONCLUSIONS

Cataract surgery performed with a low-energy femtosecond laser was non-inferior to CP; however, the FLACS group had a statistically significantly lower increase in CCT at Day 7 compared with CP. Trial registration This trial is registered at ClinicalTrials.gov on May 15, 2019, with trial registration number: NCT03953053.

Pupil Status with Low-Energy Femtosecond Laser-Assisted Cataract Surgery versus Conventional Phacoemulsification: An Intraindividual Comparative Study

Purpose

To compare the pupil changes in low-energy femtosecond laser-assisted cataract surgery (FLACS) with conventional phacoemulsification (CP) intraindividually.

Patients and Methods

A retrospective review of registered surgical data from patients that undergone uncomplicated cataract surgery in a single centre, with randomly assigned femtosecond laser-assisted cataract surgery (FLACS) to one eye and conventional phacoemulsification (CP) to the other, was performed. The recorded pupil images were evaluated at pre and post laser treatment (after suction release) and at several surgical timepoints for both techniques (FLACS and CP). Pupil areas were calculated and compared in the same eye undergone FLACS (pre vs post laser treatment), between eyes (CP vs FLACS) in the same patient and between groups. Subgroups were built regarding age and ocular comorbidity.

Results

This study involved a total of 164 eyes of 82 patients (55 female, 27 male). No statistical differences regarding the total duration of surgery (p=0.805) between FLACS and CP. Pupil measurements between pre and post laser treatment in the FLACS group showed no statistically significant differences (p=0.107). The mean change in pupil area from the beginning until the end of surgery (total variation) was 6.59±2.08 mm² in the FLACS group and 6.67±2.13 mm² in the CP group, associated to less narrowing of pupil area with FLACS, although not statistically significant (p=0.080). Comorbidity group analysis revealed less, but not significant, pupil narrowing with the FLACS technique (p=0.071). No statistically significant differences between FLACS and CP concerning age subgroups were registered.

Conclusion

This study shows no significant pupil changes, namely myosis, after low-energy FLACS pre-treatment. Comparison between techniques showed less pupil variation in FLACS as compared to CP, more markedly in eyes with comorbidities (particularly with shallow anterior chamber), although non-statistically significant.

Femtosecond laser-assisted cataract surgery: Update and perspectives

Cataract surgery is among the most frequently performed surgical procedures worldwide and has a tremendous impact on patients' quality of life. Phacoemulsification (PCS) is accepted as a standard of care; its technique has continuously evolved and already achieved good anatomical, visual, and refractive outcomes. Lasers in ophthalmology are widely used in clinical practice, femtosecond lasers (FSLs) for corneal surgery in particular. It was natural to assess the usefulness of FSL in cataract surgery as this technology was within reach. Indeed, precise and reproducible cuttings provided by FSL platforms could improve standardization of care and limit the risk associated with the human element in surgery and provide a step toward robot-assisted surgery. After docking and planning the procedure, femtosecond lasers are used to perform corneal incisions, capsulorhexis, lens fragmentation, and arcuate incisions in an automated manner. A well-constructed corneal incision is primordial as it offers safety during the procedure, self-seals afterward, and influences the refractive outcome. Capsulorhexis size, centration, and resistance to shearing influence the surgery, intraocular lens (IOL) centration and stability, and posterior capsular opacification formation. Lens fragmentation is where most of the energy is delivered into the eye, and its amount influences endothelial cell damage and potential damage to other ocular structures. The arcuate incisions offer an additional opportunity to influence postoperative astigmatism. Femtosecond laser-assisted cataract surgery (FLACS) has been a topic of research in many studies and clinical trials that attempted to assess its potential benefits and cost-effectiveness over PCS and is the subject of this mini-review.

Dexamethasone intravitreal implant along with femtosecond laser assisted cataract surgery in patients with diabetic macular edema and cataract

PURPOSE

To assess the safety and efficacy of intraoperative dexamethasone intravitreal (DEX) implant in patients with diabetic macular edema (DME) undergoing femtosecond laser assisted cataract surgery (FLACS).

METHODS

In this single-center retrospective study, the charts of patients who underwent combined FLACS and DEX implant in the previous three months were reviewed. Primary outcome measures were ocular complications; secondary outcome measures were the change of best-corrected visual acuity (BCVA) and central retinal thickness (CRT).

RESULTS

20 eyes of 20 patients were included. None developed intraoperative or postoperative complications. Mean BCVA was 20/120 (logMAR, 0.78 ± 0.31) at baseline and improved significantly to 20/63 (logMAR, 0.52 ± 0.24; p = 0.01), 20/58 (LogMAR, 0.48 ± 0.28; p < 0.001) and to 20/58 (LogMAR, 0.48 ± 0.31; p < 0.001) at month 1,2 and 3, respectively. A mean improvement of 0.30 LogMAR was recorded at month 1 and 3. Mean CRT decreased significantly from 416.6 ± 76.1 μm at baseline to 322.4 ± 46.4 μm (p < 0.001), to 300.7 ± 29.7 μm (p < 0.001), and to 319.8 ± 54.7 μm (p < 0.001) at month 1,2 and 3, respectively. Comparing to the 1-month follow-up, the largest mean reduction in CRT (112.4 ± 68.9 µm) was observed at month 2 (p = 0.001). Fourteen patients (70%) had an improvement of CRT over the first 2 months followed by a recurrence of edema at month 3.

CONCLUSION

DEX implant following FLACS seems to be a safe and effective approach for patients with coexisting cataract and DME.

The Effects of High Energy Capsulotomy on Aqueous Cytokine Profiles and Pupil Size During Femtosecond Laser-Assisted Cataract Surgery

PURPOSE

To assess whether aqueous cytokine profiles and pupil size are altered when high capsulotomy energy is used in eyes undergoing femtosecond laser-assisted cataract surgery (FLACS), and if preoperative use of a topical non-steroidal anti-inflammatory drug (NSAID) has an effect on this.

METHODS

This prospective study recruited 83 eyes (63 patients) that were allocated to four treatment groups: conventional phacoemulsification (n = 20 eyes); FLACS with 90% capsulotomy energy without NSAID pretreatment (n = 20 eyes); FLACS with 90% capsulotomy energy with NSAID pre-treatment (n = 21 eyes); and FLACS with 150% capsulotomy energy with NSAID pretreatment (n = 22 eyes). Aqueous humor was collected before and after phacoemulsification to assess cytokine profiles. Pupil size was measured before and after laser capsulotomy.

RESULTS

FLACS increased aqueous concentrations of pros-taglandin E₂ (PGE₂), interferon γ (IFN-γ), and interleukin 6 (IL-6) compared to conventional phacoemulsification. However, when increasing capsulotomy energy from 90% to 150% (with topical NSAID pretreatment), there was no significant increase in aqueous concentrations of PGE₂ (37.7 ± 21.7 vs 33.6 ± 27.6 pg/mL, P = .99), IFN-γ (3.6 ± 1.1 vs 3.6 ± 0.8 pg/mL, P = .99), or IL-6 (7.1 ± 2.9 vs 6.3 ± 2.4 pg/mL, P = .99). For 90% and 150% capsulotomy energy, there was significant miosis following laser capsulotomy. Increased PGE₂ concentration was significantly correlated with a reduction in pupil area (r = -0.58, P < .001) and pupil diameter (r = -0.57, P < .001). However, when a topical NSAID was given preoperatively, there was no difference in the degree of miosis between the 90% and 150% capsulotomy energy groups.

CONCLUSIONS

Pretreatment with a topical NSAID prevented a rise in PGE₂, IFN-γ, and IL-6 levels and excessive miosis when a higher capsulotomy energy was used. When a topical NSAID is used preoperatively, it is safe to use higher capsulotomy energy settings (with a low pulse energy femtosecond laser system) to achieve a satisfactory capsulotomy. [J Refract Surg. 2022;38(9):587-594.].

Prostaglandin Release After Low-Energy Femtosecond Laser-Assisted Cataract Surgery Without Anti-Inflammatory Drug Premedication

PURPOSE

To compare prostaglandin E2 (PGE-2) levels in the aqueous and pupil diameter in patients undergoing low-pulse energy femtosecond laser-assisted cataract surgery (LCS) without non-steroidal anti-inflammatory (NSAID) pretreatment with either fragmentation or capsulotomy performed first.

DESIGN

Prospective, randomized, fellow-eye controlled comparison.

METHODS

This study was undertaken at the Department of Ophthalmology, Medical University of Vienna. The population consisted of 140 eyes of 70 patients with bilateral age-related cataract. Bilateral same-day LCS with either anterior capsulotomy before lens fragmentation (Caps-First) in one eye or vice versa (Frag-First) in a random sequence were performed. Aqueous was tapped 5 minutes after LCS and PGE-2 concentration was analyzed. Pupil diameters were recorded immediately before and after femtosecond laser pretreatment. The main outcome measure was PGE-2 concentrations in picograms/milliliter and pupil diameter in millimeters.

RESULTS

Mean PGE-2 concentrations were 42.0 ± 63.7 pg/mL in the Caps-First group versus 71.8 ± 160.7 pg/mL with the Frag-First group (P = .186). Mean pupil diameters before and after pretreatment were 7.6 ± 0.8 mm and 7.6 ± 0.8 mm, respectively (P = .871). Mean PGE-2 concentrations and pupil diameters did not show any significant difference between time points or groups.

CONCLUSIONS

Low-energy femtosecond laser pretreatment did not increase PGE-2 levels in the absence of NSAID pretreatment. This was independent of whether capsulotomy or fragmentation was performed first. Moreover, no pupillary miosis was observed.

Safety of femtosecond laser-assisted cataract surgery versus conventional phacoemulsification for cataract: A meta-analysis and systematic review

Purpose

To compare the complications of femtosecond laser-assisted cataract surgery (FLACS) with those of conventional phacoemulsification surgery (CPS) for age-related cataracts.

Methods

PubMed, Cochrane Library, and EMBASE were systematically searched for studies comparing FLACS and CPS. Outcomes were operative complications, including the intraoperative capsule tear, postoperative corneal edema, macular edema, uncontrolled IOP, etc. The effect measures were weighted with odds ratios with 95% CIs.

Results

Nineteen RCTs and 18 cohort studies, including 24,806 eyes (11,375 of the FLACS group and 13,431 of the CPS group), were identified. There were no significant differences between the two groups in anterior capsule tear, corneal edema, macular edema, uncontrolled IOP, vitreous loss, posterior vitreous detachment, etc. Posterior capsule tear rate showed a significantly lower in RCT subgroups (P ​= ​0.04) and without differences in total (P ​= ​0.63). Significant differences were observed in the incidence of descemet membrane tear/trauma (P ​= ​0.02) and IFIS/iris trauma (P ​= ​0.04. Additionally, The FLACS specific complications showed a significantly higher rate of miosis (P ​< ​0.0001), corneal epithelial defect (P ​= ​0.001), corneal haze (P ​= ​0.002), and subconjunctival hemorrhage (P ​= ​0.01).

Conclusions

FLACS maintains the same safety compared with CPS in terms of all intraoperative and postoperative complications. Although FLACS did show a statistically significant difference for several FLACS specific complications, it would not influence the visual outcome and heal itself.

Ultrasound energy consumption and macular changes with manual and femtolaser-assisted high-fluidics cataract surgery: a prospective randomized comparison

PURPOSE

The purpose of the study was to compare ultrasound (US) consumption and central macular thickness (CMT) and volume changes with manual and femtosecond laser (FSL)-assisted cataract nucleus workup.

METHODS

Sixty patients scheduled for immediate sequential bilateral surgery underwent a prospective randomized intraindividual comparison of nucleus sector fragmentation performed manually in one eye and with low-energy FSL assistance in the partner eye, followed by high-fluidics phacoaspiration with a maximum US power of 30%. Ultrasound (US) energy consumption and macular thickness and volume were compared as measured by intraoperative effective phacoemulsification time (EPT) and high-resolution spectral domain optical coherence tomography pre- and 1 week, 3 weeks and 6 weeks postoperatively. Results are presented as means ± SD or medians [min; max].

RESULTS

Fifty-two patients completed the full follow-up. For the manual and FSL-assisted groups, nuclear hardness was almost identical with a mean LOCS III grade of 2.44 ± 1.08 and 2.50 ± 1.00 (p = 0.371). Median EPT was 1.40 [0.2; 8.3] and 1.25 [0.2; 9.4] seconds. Median preoperative CMT was 276.50 [263.25; 289.75] µm and 276.00 [262.00; 290.00] µm. Median postoperative CMT was 278.00 [260.50; 288.00] versus 275.50 [264.00; 290.50] µm at 1 week, 279.50 [266.75; 292.25] versus 280.00 [266.50; 294.50] µm at 3 weeks and 280.50 [268.00, 293.75] versus 279.50 [264.75; 295.25] µm at 6 weeks. Differences in CMT and total macular volume between the groups were not statistically significant at any point in time.

CONCLUSION

Femtosecond laser (FSL) prefragmentation of the nucleus into six sectors did not reduce US energy consumption compared with manual splitting of the nucleus into four quadrants in this particular surgical setting. Sectorial FSL-prechopping with the low-energy FSL used had no additional impact on postoperative macular thickness and volume.

Randomized Controlled Trial Comparing 1-Year Outcomes of Low-Energy Femtosecond Laser-Assisted Cataract Surgery versus Conventional Phacoemulsification

Purpose: To compare 1-year clinical outcomes, phacoemulsification energy, aqueous profiles, and patient-reported outcomes of low-energy femtosecond laser-assisted cataract surgery (FLACS) vs. conventional phacoemulsification.

Methods: The study is a randomized controlled trial (RCT) with paired-eye design. Eighty-five patients were randomized to receive FLACS (Ziemer LDV Z8) in one eye and conventional phacoemulsification in the fellow eye. Clinical data including phacoemulsification energy parameters (cumulative dissipated energy, phacoemulsification power, and phacoemulsification time), uncorrected and corrected distance visual acuities (UCDVA and BCDVA), manifest refraction spherical equivalent (MRSE), central corneal thickness (CCT), endothelial cell count (ECC), anterior chamber flare, and post-operative complications were obtained for 1 year. Aqueous humor was collected for the analysis of prostaglandin (PGE)₂, cytokines and chemokines concentrations. Patients' reported-outcomes on surgical experiences were evaluated using an in-house questionnaire.

Results: Compared to conventional phacoemulsification, the low-energy assisted FLACS group had significantly less ECC reduction at 3 months (1.5 ± 0.3% vs. 7.0 ± 2.4%; P < 0.01) and 1 year (8.2 ± 2.8% vs. 11.2 ± 3.6%; P = 0.03). There were no significant differences in the phacoemulsification energy parameters, UCDVA, BCDVA, MRSE, CCT, occurrence of post-operative complications between the 2 groups throughout post-operative 1 year. Patients' subjective surgical experiences, including the surgical duration and perceived inconvenience, were comparable between the 2 groups. FLACS resulted in significantly higher aqueous PGE₂ (P < 0.01), interleukin (IL)-6 (P = 0.03), IL-8 (P = 0.03), and interferon (IFN)-γ (P = 0.04) concentrations and greater anterior chamber flare at 1 day (P = 0.02).

Conclusions: Our RCT presented 1-year longitudinal clinical and laboratory data. The long-term ECC result was more favorable in low-energy FLACS. The rest of the intraoperative and post-operative outcomes, as well as patient-reported outcomes, were comparable between these two procedures.

Effect of preoperative eyedrops on cytokine concentrations in aqueous humor of patients undergoing femtosecond laser-assisted cataract surgery

PURPOSE

To compare the anti-inflammatory activity of preoperatively applied eyedrops, as determined by cytokine concentrations in aqueous humor collected during surgery in patients undergoing femtosecond laser-assisted cataract surgery.

METHODS

A total of 120 patients undergoing femtosecond laser-assisted cataract surgery were randomly assigned to four groups of 30 patients each. Groups were administered 0.1% fluorometholone eyedrops, 0.45% ketorolac tromethamine eyedrops, both 0.1% fluorometholone and 0.45% ketorolac tromethamine eyedrops, or no eyedrops. Eyedrops were instilled 1 h, 20 min, and just before surgery. After anterior capsulotomy and nuclear fragmentation using a femtosecond laser, 0.1 cc aqueous humor was obtained using a needle and syringe. Cytokine and prostaglandin E₂ (PGE₂) concentrations were quantitatively determined.

RESULTS

The 120 patients included 59 men and 61 women, of mean age 65.02 years. The mean interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) concentrations after treatment did not differ significantly in the four groups. The average interleukin-8 (IL-8) concentrations were significantly lower in the fluorometholone (4.80 pg/mL), ketorolac tromethamine (4.84 pg/mL), and fluorometholone + ketorolac tromethamine (4.68 pg/mL) groups than in the control group (6.83 pg/mL). Furthermore, the average PGE₂ concentrations were significantly lower in the ketorolac tromethamine (270.04 pg/mL) and fluorometholone + ketorolac tromethamine (239.00 pg/mL) groups, but not in the fluorometholone (393.16 pg/mL) group, than in the control group (472.36 pg/mL).

CONCLUSION

Preoperative fluorometholone instillation reduced IL-8, and ketorolac tromethamine instillation reduced IL-8 and PGE₂, in aqueous humor of patients undergoing femtosecond laser surgery, with the combination of both eyedrops being more effective than either alone.

TRIAL REGISTRATION

KCT0005717.

Comparing corneal outcome between femtosecond laser-assisted cataract surgery and conventional phaco surgery in Fuchs' endothelial dystrophy patients: a randomized pilot study with 6mo follow up

AIM

To compare the corneal outcome in Fuchs' endothelial dystrophy (FED) patients between femtosecond laser-assisted cataract surgery (FLACS) and conventional phaco surgery (CPS).

METHODS

This was a randomized controlled study comparing one eye surgery by FLACS and the contralateral eye operated by CPS (stop and chop technique) in FED patients. Central corneal thickness, corneal light backscatter, corneal densitometry, and central corneal endothelial cell count and hexagonality (noncontact endothelial cell microscope), and corrected distance visual acuity (CDVA) were assessed preoperatively and at day 1, 40, and 180 postoperatively.

RESULTS

Totally 31 patients (16 women) were included. At day 40 postoperatively, the mean endothelial cell loss (ECL) was 23.67% by FLACS and 17.30% by CPS (P=0.53). At day 180 postoperatively, ECL was 25.58% in FLACS and 21.32% in CPS (P=0.69). Densitometry data in all layers and all annuli from anterior layer to posterior layer in annuli 0-2, 2-6, 6-10 and 10-12, total densitometry with all layers and all annuli was performed. A significant difference was found in 6-10 (posterior layer) at day 1 with -1.42 grayscale units (GSU; 95%CI: -2.66 to -0.19, P=0.02). In 10-12 (anterior layer, central layer and all layers) at day 40 were significant different with 7.7 (95%CI: 1.89 to 13.50, P=0.009), 3.97 (95%CI: 0.23 to 7.71, P=0.03), 4.73 GSU (95%CI: 0.71 to 8.75, P=0.02), respectively. In the remaining parameters we found no difference between the two groups (P>0.05). Three CPS eyes suffered from corneal decompensation.

CONCLUSION

There is no significant difference in corneal outcome between FLACS and CPS. Endothelial cell density and pentacam corneal outcome may be inadequate as outcome parameters in FED patients.

Perioperative pupil size in low-energy femtosecond laser-assisted cataract surgery

PURPOSE

To assess potential changes in pupil size during femtosecond laser-assisted cataract surgery (FLACS) using a low-energy laser system.

METHODS

The pupil sizes of eyes undergoing FLACS were measured using the Ziemer LDV Z8 by extracting images from the laser software after each of the following steps: application of suction, lens fragmentation, and capsulotomy. Furthermore, the pupil diameters were measured based on preoperative surgical microscope images and after releasing the suction. Paired t-test and the two one-sided tests (TOST) procedure were used for statistical analyses. The horizontal and vertical pupil diameters were compared in each of the steps with preoperative values.

RESULTS

Data were available for 52 eyes (52 patients, mean age 73.4 years, range 51-87 years). The equivalence between mean preoperative pupil size and status immediately after femtosecond laser treatment was confirmed (p<0.001; 95% confidence interval [-0.0637, 0.0287] for horizontal and p<0.001; 95% CI [-0.0158, 0.0859] for vertical diameter). There was statistically significant horizontal and vertical enlargement of pupil diameters between 0.15 and 0.24 mm during the laser treatment steps as compared with preoperative values (all p values <0.001).

CONCLUSIONS

No progressive pupil narrowing was observed using low-energy FLACS. Although a suction-induced, slight increase in pupil area became apparent, this effect was completely reversible after removing the laser interface.

Surgical outcomes with high and low pulse energy femtosecond laser systems for cataract surgery

Currently, there is no clear consensus in cataract surgery if low compared to high energy femto-lasers may enable better capsulotomy quality and induce lower inflammatory response. Therefore, the aim of this study was to compare the intra-operative outcomes achieved with high and low pulse energy femtosecond laser systems for cataract surgery. The charts of 200 eyes of 200 patients aged 68.3 ± 10.3 years who had undergone femtosecond laser-assisted cataract surgery using either group 1 high pulse energy: LenSx (Alcon Laboratories) (N = 100) or group 2 low pulse energy: FEMTO LDV Z8 (Ziemer) (N = 100) laser were reviewed retrospectively. Integrity of anterior capsulotomy, classified as (1) complete (free-floating or with minor microadhesions), (2) incomplete and (3) with capsular tears, intraoperative completeness of the clear corneal incisions (CCI, main incision and side port), incidences of intraoperative miosis and incidence of subconjunctival hemorrhage were evaluated and compared between the two groups. The proportion of complete capsulotomies was significantly higher in the group 2 than the group 1 (100% vs 94%; p = 0.03). The incidences of intraoperative miosis (0% vs 19%) and subconjunctival hemorrhage (1% vs 63%) were significantly lower in the group 2 than the group 1 (p < 0.001). Completeness of the main incision was comparable (97% vs 95%; p = 0.721) between the two groups. Although not statistically significant, the completeness of side-port incision was slightly better in the group 2 than the group 1 (91% vs 86%). Low energy laser system performed significantly better in terms of completeness of capsulotomy, intraoperative miosis and sub-conjunctival hemorrhage, compared with high energy laser; the CCI outcomes were comparable.

Femtosecond-Laser Assisted Surgery of the Eye: Overview and Impact of the Low-Energy Concept

This article provides an overview of both established and innovative applications of femtosecond (fs)-laser-assisted surgical techniques in ophthalmology. Fs-laser technology is unique because it allows cutting tissue at very high precision inside the eye. Fs lasers are mainly used for surgery of the human cornea and lens. New areas of application in ophthalmology are on the horizon. The latest improvement is the high pulse frequency, low-energy concept; by enlarging the numerical aperture of the focusing optics, the pulse energy threshold for optical breakdown decreases, and cutting with practically no side effects is enabled.

Evaluation of femtosecond laser-assisted anterior capsulotomy in the presence of ophthalmic viscoelastic devices (OVDs)

The introduction of femtosecond laser-assisted cataract surgery is an alternative approach to conventional cataract surgery. Our study aimed to determine the effectiveness of femtosecond laser-assisted capsulotomy in the presence of different ophthalmic viscoelastic devices (OVDs) in the anterior chamber. Fresh porcine eyes (n = 96) underwent LDV Z8-assisted anterior capsulotomy, either in the presence of an OVD (Viscoat, Provisc, Healon, Healon GV or HPMC) or without, using 90% and 150% energies respectively. Following that, the capsule circularity, tag’s arc-length, tag-length, tag-area and rupture strength (mN) of the residual capsular bag were evaluated. We found that increasing energy from 90 to 150% across the OVD sub-groups improved the studied capsulotomy parameters. Amongst the 90% energy sub-groups, the circularity and tag-parameters were worse with Viscoat and Healon GV, which have higher refractive index and viscosity compared to the aqueous humour. Using 150% energy, Healon GV showed a significantly worse total arc-length (p = 0.01), total tag-length (p = 0.03) and total tag-area (p = 0.05) compared to the control group. We concluded that; an OVD with a refractive index similar to aqueous humour and lower viscosity, such as Healon or Provisc, as well as a higher energy setting, are recommended, to enhance the efficacy of laser capsulotomy.

Cystoid Macular Edema Following Cataract Surgery with Low-Energy Femtosecond Laser versus Conventional Phacoemulsification

Purpose

To compare postoperative changes in central subfield macular thickness (CSMT) and prevalence of cystoid macular edema (CME) in patients undergoing cataract surgery with low-energy femtosecond laser versus standard phacoemulsification.

Design

This was a retrospective comparative real-world study.

Methods

Postoperative data of 252 eyes of 165 patients were collected: 138 eyes received low-energy femtosecond laser-assisted cataract surgery (FLACS) and 114 eyes underwent conventional phacoemulsification cataract surgery (CPCS). Postoperative changes in CSMT and prevalence of CME were compared between the two groups.

Results

There was a significant increase in mean CSMT from preoperative to postoperative values at 2.5 months in both the FLACS and CPCS group (p<0.001). Mean change (preoperation to 2.5 months postoperation) in CSMT was 6.2±11.5 µm in the FLACS group and 7.3±26.6 µm in the CPCS group, which was statistically significant but clinically not relevant. Comparison of mean changes in CSMT (preoperation to 2.5 months postoperation) between the FLACS and CPCS groups revealed no significant differences. The rate of pseudophakic CME (PCME) development was lower in the FLACS group (1.4%) than the CPCS group (4.4%; p=0.247). When using PREMED criteria to define clinically significant PCME, only 0.7% patients in the FLACS group and 1.8% in the CPCS group showed development of clinically significant PCME (p=0.586).

Conclusion

The mean change in CSMT and occurrence of postoperative CME was lower in the low-energy FLACS group than the standard-phacoemulsification group; however, the difference was not statistically significant.

Long-Term Evaluation of Capsulotomy Shape and Posterior Capsule Opacification after Low-Energy Bimanual Femtosecond Laser-Assisted Cataract Surgery

Purpose

To evaluate capsulotomy shape and posterior capsule opacification (PCO) during an 18-month follow-up for bimanual femtosecond laser-assisted cataract surgery (FLACS).

Methods

74 eyes operated by a well-trained surgeon with bimanual FLACS technique using low-energy LDV Z8 (Ziemer Ophthalmic Systems AG, Port, Switzerland) were included in the study. The follow-up period was 18 ± 2 months. Another 91 eyes, which underwent standard bimanual microincision cataract surgery (B-MICS), served as a control group. In all cases, a BunnyLens AF (Hanita Lenses, Israel) intraocular lens was implanted in the bag. A digital image of the capsule with slit-lamp retroillumination was performed in all patients at 18 months of follow-up. Image analysis software (ImageJ) was used to evaluate the shape of the capsulotomy in terms of diameter, area, and circularity. PCO score was evaluated using EPCO 2000 software. Best corrected visual acuity (BCVA) and endothelial cell count (ECC) were evaluated before and after surgery at 1 and 18 ± 2 months.

Results

At 18 months, mean capsulotomy diameter was 5.34 ± 0.21 mm while capsulorhexis was 5.87 ± 0.37 mm (p < 0.001) and the deviation area from baseline was 1.13 ± 1.76 mm² in FLACS and 2.67 ± 1.69 mm² in B-MICS (p < 0.001). Capsulotomy circularity was 0.94 ± 0.04 while capsulorhexis was 0.83 ± 0.07 (p < 0.001). EPCO score was 0.050 ± 0.081 in the FLACS group and 0.122 ± 0.239 in the B-MICS group (p=0.03). The mean BCVA improvement was significant in both groups, without a significant difference at 18 months. We noticed a statistically significant difference in endothelial cell loss at 18 months (FLACS 12.4% and B-MICS 18.1%; p=0.017).

Conclusions

Bimanual FLACS is a safe and effective technique, as determined in a long-term follow-up. Capsulotomy shape presented higher stability and circularity in the FLACS group over the 18-month observation period. FLACS resulted in lower PCO scores and endothelial cell loss at 18 months in comparison to B-MICS standard technique.

Comparative evaluation of femtosecond laser-assisted cataract surgery and conventional phacoemulsification in eyes with a shallow anterior chamber

PURPOSE

To compare intraoperative performance and postoperative outcomes between femtosecond laser-assisted cataract surgery (FLACS) and conventional phacoemulsification in eyes with a shallow anterior chamber (AC).

SETTING

Iladevi Cataract & IOL Research Centre, India.

DESIGN

Prospective randomized masked clinical study.

METHODS

Patients undergoing cataract surgery with a shallow AC (<2.5 mm) were randomized to have FLACS (Group 1, n = 91) or conventional phacoemulsification (Group 2, n = 91). Patients were followed up at 1 day, 1 week, and at 1, 3, and 6 months. The primary outcome measure was central corneal thickness (CCT). The secondary outcome measures were corneal clarity, AC cells and flare, endothelial cell density (ECD), coefficient of variance, hexagonality, and uncorrected distance visual acuity (UDVA) at 1 week.

RESULTS

The study comprised 182 eyes (91 in each group) The cumulative dissipative energy was lower in the FLACS group (P < .05). The mean CCT was significantly lower with FLACS (540.40 μm + 49.40 [SD] vs 556 + 12.5 μm, P = .03) at 1 day and 1 week (535.5 + 44.3 μm vs 551 + 40.8 μm, P = .04), with fewer eyes having higher than grade 2 AC cells and flare with FLACS (85% vs 72%, P = .056) at 1 day and 1 week (15% vs 28%, P = .03). At 1 week, the UDVA was better with FLACS (0.089 ± 0.31 logarithm of the minimum angle of resolution [logMAR] vs 0.178 ± 0.65 logMAR, P = .042). At 6 months, the reduction in ECD was lower in the FLACS group; however, the difference was not statistically significant.

CONCLUSION

In eyes with shallow ACs, compared with conventional phacoemulsification, FLACS maintained clearer corneas, showed less increase in CCT, lower AC inflammation, and better UDVA in the early postoperative period.

Evaluation of femtosecond laser-assisted cataract surgery after 10 years of clinical application

INTRODUCTION

Femtosecond laser-assisted cataract surgery (FLACS) has been considered a technological advance in modern cataract surgery. After years of experience, it has been observed that clinical outcomes had more complications than expected at the beginning. The aim of this study is to compare the benefits and disadvantages of the FLACS technique with conventional cataract surgery.

METHOD

The PubMed and Web of Science platforms were used to search for scientific literature.

RESULTS

The FLACS has currently improved the surgical technique in terms of the shorter ultrasound time used and the lower loss of endothelial cells. Likewise, the centration of capsulotomy and the correction of astigmatism with arcuate incisions have also been improved. As disadvantages, are the high cost of the laser, the intraoperative capsular complications, the induction of intraoperative myosis, and the learning curve of the technique.

CONCLUSIONS

The FLACS technique is considered beneficial for specific cases, such as patients with scheduled premium surgery, or with low endothelial cell count. However, it is believed that given the technological cost it is not a cost effective technique for most standard cases in our daily clinical practice.

The benefits and drawbacks of femtosecond laser-assisted cataract surgery

INTRODUCTION

Since the introduction, femtosecond laser-assisted cataract surgery was believed to revolutionize cataract surgery. However, the judgment of clinical benefit was found to be far more complex than initially might have been thought. The aim of this review was to analyze the benefits and drawbacks of femtosecond laser-assisted cataract surgery compared with traditional phacoemulsification cataract surgery.

METHODS

PubMed and the Web of Science were used to search the medical literature. The following keywords were searched in various combinations: femtosecond laser, femtosecond laser-assisted cataract surgery, phacoemulsification cataract surgery, FLACS.

RESULTS

The benefits of femtosecond laser-assisted cataract surgery include lower cumulated phacoemulsification time and endothelial cell loss, perfect centration of the capsulotomy, and opportunity to perform precise femtosecond-assisted arcuate keratotomy incisions. The major disadvantages of femtosecond laser-assisted cataract surgery are high cost of the laser and the disposables for surgery, femtosecond laser-assisted cataract surgery-specific intraoperative capsular complications, as well as the risk of intraoperative miosis and the learning curve.

CONCLUSION

Femtosecond laser-assisted cataract surgery seems to be beneficial in some groups of patients, that is, with low baseline endothelial cell count, or those planning to receive multifocal intraocular lens. Nevertheless, having considered that the advantages of femtosecond laser-assisted cataract surgery might not be clear in every routine case, it cannot be considered as cost-effective.

Application of Femtosecond Laser in Anterior Segment Surgery

Femtosecond laser (FSL) is a near-infrared laser that can create reliable and reproducible tissue cutting with minimal damage to adjacent tissue. As the laser can also create incisions with various orientations, depths, and shapes, it is expected to be a useful tool for anterior segment surgery, such as cornea, refractive, and cataract surgery. In this review, the authors will introduce the application of FSL in various anterior segment surgeries and discuss the results of studies regarding the efficacy and safety of FSL in cornea, refractive, and cataract surgery. Experimental studies regarding the potential use of FSL will also be introduced. The studies discussed in this review suggest that FSL may be a useful tool for improving the prognosis and safety of surgeries of the anterior segment.

Methods for achieving adequate pupil size in cataract surgery

PURPOSE OF REVIEW

Cataract surgery is the most common surgical procedure performed worldwide. Small pupils have been an eternal challenge for cataract surgeons; insufficient pupil dilation is associated with increased complication rates, including capsule rupture, vitreous loss, iris trauma or postoperative inflammation. The aim of the current review is to present the methods for pupil dilation and the risk factors for a small pupil in a cataract patient.

RECENT FINDINGS

Risk factors for intraoperative small pupil include diabetes, intraoperative floppy iris syndrome, pseudoexfoliation syndrome, receiving glaucoma medications, having undergone previous ocular surgery and iris sphincter sclerosis from aging. There is a wide range of options to manage the small pupil, including pharmacological treatment, mechanical stretching, dilation with iris hooks or pupil expanders. We recommend a stepwise approach for intraoperative pupil dilation, from pharmacological mydriasis to pupil expanders.

SUMMARY

The current article discusses risk factors for a small pupil and the methods for pupil dilation in a cataract patient. Every cataract surgeon needs to be ready to cope with a small pupil, both manifesting preoperatively and intraoperatively.

[Prevention of intraoperative miosis in femtosecond laser-assisted phaco surgery]

INTRODUCTION

Prevention of intraoperative miosis in hybrid (femtosecond laser-assisted) phacoemulsification is a relevant problem of cataract surgery.

PURPOSE

Development and clinical study of an effective method for preventing intraoperative miosis in hybrid (femtosecond laser-assisted) phacoemulsification.

MATERIAL AND METHODS

Hybrid phacoemulsification was performed in 300 patients (300 eyes). The first group (100 eyes) 3 days prior to the surgery was prescribed instillations of 0.1% indomethacin 3 times a day and 3 times in 2 hours before surgery at 30 minute intervals. The second group (100 eyes) 3 days prior to the surgery was prescribed instillations of 0.1% indomethacin 3 times a day, 3 times in 2 hours before the surgery at 30 minute intervals, and 1 hour before the surgery an additional intramuscular injection of diclofenac. The third group (control, 100 eyes) 2 hours before the operation was prescribed instillations of 0.1% indomethacin, 3 times at 30 minute intervals. The diameter of the pupil was evaluated before the beginning of femtosecond laser stage and before the opening of anterior chamber during the second stage of the operation.

RESULTS

When the interval between the femtosecond laser stage and emulsification of the nucleus fragments was maintained at less than 15 minutes, pronounced decrease of the pupil (more than 2 mm) was noted in 8.2% of cases in the first group, 6.7% in the second group and 14.1% in third (control) group; mean values of pupil narrowing were 0.68±0.27 mm in the 1st group, 0.63±0.25 mm in the 2nd group, and 0.93±0.39 mm (p<0.05) in the third group.

CONCLUSION

The clinical study showed high efficiency of the proposed methods for prevention of intraoperative miosis in hybrid (femtosecond laser-assisted) phaco surgery. An important factor affecting intraoperative narrowing of the pupil is the time interval between the femtolaser stage of the operation and emulsification of the nucleus fragments, which should not exceed 15 minutes.

Refractive Laser-Assisted Cataract Surgery versus Conventional Manual Surgery: Comparing Efficacy and Safety in 3144 Eyes

PURPOSE

To report on outcomes of the efficacy and safety in 1 of the largest series of eyes undergoing either conventional manual cataract surgery (MCS) or refractive femtosecond laser-assisted cataract surgery (ReLACS).

DESIGN

Retrospective, consecutive, interventional comparative case series.

METHODS

This study included 3144 consecutive eyes, of which 1580 were treated via MCS, and 1564 were treated via ReLACS at Uptown Surgical Centre in Vaughan, Ontario, Canada. Preoperative characteristics, best corrected visual acuity (BCVA), mean absolute spherical error (MAE), rates of intraoperative posterior capsular rupture, and postoperative complications were evaluated.

RESULTS

Across all eyes, ReLACS was superior to MCS for reducing surgical time (MCS: 7.7 ± 0.1 min vs ReLACS: 6.8 ± 0.1 min, P < 0.001); was less commonly associated with postoperative cystoid macular edema (OR = 0.36, 95% CI: 0.14-0.91, P = 0.031) and more commonly reduced MAE (MCS: 0.60 ± 0.02 diopters (D) vs ReLACS: 0.54 ± 0.02 D, P = 0.02). There were no differences in rates of posterior capsular rupture (P = 0.918), overall postoperative complications (P = 0.088) or final BCVA (P = 0.881). When analyzing a subgroup of more difficult cases (n = 833), ReLACS was superior to MCS for: 1) being more likely to yield an improvement of more than 0.1 logarithm of the minimum angle of resolution BCVA (OR = 1.80, 95% CI: 1.15-2.74, P = 0.01); 2) reducing MAE (MCS: 0.73 ± 0.3 D vs ReLACS: 0.60 ± 0.27 D, P = 0.04); and 3) being more likely to yield an MAE within 0.5 D (OR = 1.61, 95% CI: 1.11-2.33, P = 0.012).

CONCLUSIONS

Across all eyes, our results support that ReLACS and MCS yield similar outcomes. However, our results show trends toward a more pronounced benefit of ReLACS compared to MCS when treating more difficult eyes.

Changes in Pupil Area during Low-energy Femtosecond Laser-assisted Cataract Surgery

Purpose

To study the potential changes in pupil area within low-energy femtosecond-laser assisted cataract surgery (FLACS).

Methods

A retrospective assessment of the pupil size was performed in the eyes undergoing FLACS using the Ziemer LDV Z8. We measured the pupil diameters as part of the images taken preoperatively and at the completion of laser pretreatment (after releasing the suction). We calculated the pupil area in 40 eyes of 40 patients (14 right and 26 left eyes). The mean ± standard deviation (SD) of age of the patients was 74 ± 7.4 years (range: 51-87). Paired t-test was used for statistical analyses. Subgroups were built with reference to age and preoperative pupil area (smaller than or equal to the median versus larger than the median).

Results

The mean ± SD axial length, anterior chamber depth, white-to-white distance and lens thickness were 24.01 ± 1.47, 3.23 ± 0.4, 11.97 ± 0.49, and 4.59 ± 0.41 mm, respectively. The mean ± SD pupil area was 39.33 ± 7.1 mm 2 preoperatively and 39.3 ± 6.75 mm 2 after laser pretreatment. The mean ± SD change in pupil area was -0.03 ± 2.12 mm 2 . There were no statistically significant changes between preoperative and post-laser pupil areas (P = 0.93, 95% CI: -0.71 to 0.65). Comparisons within subgroups also did not detect pupil area reduction.

Conclusion

This study did not detect statistically significant changes in pupil area after laser pretreatment using low-energy FLACS. This observation is in contrast to previous studies using other laser platforms.

Bimanual femtosecond laser-assisted cataract surgery compared to standard bimanual phacoemulsification: A case–control study

Purpose:

To evaluate the efficacy and safety of bimanual, low-energy femtosecond laser-assisted cataract surgery with 1.4-mm microincisions compared to standard bimanual phacoemulsification (bimanual microincision cataract surgery).

Design:

Prospective, non-randomized comparative case series.

Methods:

Bimanual femtosecond laser-assisted cataract surgery with microincisions was performed on 80 eyes (Group A) with the low-energy Ziemer LDV Z8; a matched case–control series of 80 eyes performed with standard bimanual microincision cataract surgery technique was selected for comparison (Group B). All interventions were performed by the same experienced surgeon. Intraoperative parameters were recorded as well as intra- and postoperative complications. Best corrected visual acuity, surgically induced astigmatism, central corneal thickness and endothelial cell count were evaluated before surgery and at 1 and 3 months post intervention.

Results:

The mean effective phaco times were 3.79 ± 2.19 s (Group A) and 4.49 ± 1.84 s (Group B) (p = 0.041). No major intra- or postoperative complications occurred. An overall significant mean best corrected visual acuity improvement was noted at 3 months, but was not statistically different between the groups. No significant changes were observed for surgically induced astigmatism or corneal pachymetry. A significant loss of endothelial cell count in both groups was detected at 3 months, with Group A reporting a significantly lower endothelial cell count loss compared to Group B (p = 0.009).

Conclusion:

Bimanual, low-energy femtosecond laser-assisted cataract surgery with 1.4-mm microincisions by an expert surgeon was proven to be safe and effective in this study. This technique has advantages compared with standard bimanual microincision cataract surgery in terms of endothelial preservation.

Efficacy of 0.015% intracameral epinephrine for significant miosis induced by photodisruption during femtosecond laser-assisted cataract surgery

Despite the various advantages of femtosecond laser-assisted cataract surgery (FLACS), pupillary constriction during laser photodisruption is considered one of the most unfavorable events. This study aimed to investigate the efficacy of intracameral 0.015% epinephrine injection for miosis after laser pretreatment during FLACS.A total of 82 patients who underwent FLACS for age-related cataracts were investigated in this retrospective study. The epinephrine group included patients who received intracameral epinephrine injection for miosis after femtosecond laser pretreatment, while the no-epinephrine group included the patients who underwent FLACS without intracameral epinephrine due to minimal miosis. Quantitative pupil area measurements were performed through the analysis of captured images extracted from surgical videos of both femtosecond laser pretreatment and phacoemulsification.Laser photodisruption induced miosis in both groups, although the degree of miosis was greater in the epinephrine group (4.65 ± 0.87 mm) than in the no-epinephrine group (6.30 ± 0.65 mm; P < .001). The intracameral epinephrine injection significantly increased the pupil diameter from 4.65 ± 0.87 to 5.49 ± 0.76 mm (21.61 ± 22.68%; P < .001) and the pupil area from 70.28 ± 24.46 to 96.49 ± 25.24 mm (52.89 ± 63.54%; P < .001). After additional viscomydriasis, there was no difference between groups in pupil diameter (epinephrine vs no-epinephrine group; 6.10 ± 0.77 vs 6.39 ± 0.65 mm; P = .073).A single intracameral injection of 0.015% epinephrine provided immediate and appropriate redilation of pupil in patients with significant miosis after femtosecond laser photodisruption. Intracameral epinephrine is a simple and practical option for pupil redilation in case of miosis during FLACS.

The Effect of NSAID Pretreatment on Aqueous Humor Prostaglandin E2 Concentration in Eyes Undergoing Femtosecond Laser-Assisted Capsulotomy

PURPOSE

To assess aqueous humor concentration of prostaglandin E2 (PGE2) after capsulotomy creation using a femtosecond laser (FLAC) in patients pretreated with short-term topical ketorolac versus patients without pretreatment.

METHODS

This prospective study comprised consecutive patients scheduled to undergo cataract surgery using a femtosecond laser platform to perform only capsulotomies. An identical protocol for preoperative mydriasis was used for all the eyes included in the study, while aqueous humor was extracted from the anterior chamber of all patients immediately after the initial side port incision. ELISA was performed to quantify aqueous humor PGE2. The patients were divided into 2 groups; in group 1, the patients received short-term topical ketorolac preoperatively, while the patients in group 2 did not receive NSAID pretreatment.

RESULTS

Twenty eyes of 20 patients were included in the study (10 eyes in each group). Mean concentration of aqueous humor PGE2 after FLAC was 392.16 ± 162.00 pg/ml and 622.63 ± 331.84 pg/ml for groups 1 and 2, respectively. A statistically significant difference in aqueous humor PGE2 concentration between the two groups (p < 0.05) was demonstrated, with the eyes that received ketorolac pretreatment demonstrating a lower concentration of PGE2.

CONCLUSION

Short-term topical use of ketorolac prior to FLAC seems to prevent excessive release of PGE2 in the anterior chamber of the eyes that received NSAID pretreatment when compared to the eyes that did not receive NSAIDs preoperatively.

[Morphological and clinical aspects of anterior capsulotomy in femtosecond laser-assisted cataract surgery]

The review covers morphological and clinical aspects of femtosecond laser-assisted anterior capsulotomy in cataract surgery. Literature data suggests that femtosecond laser-assisted capsulotomy is more accurate in size, shape, and centration than manual. Femtosecond laser-assisted anterior capsulotomy improves the accuracy of IOL positioning within the capsular bag.

Decision-making and management of uveitic cataract

The visual outcome of uveitic cataract surgery depends on the underlying uveitic diagnosis, the presence of vision-limiting pathology and perioperative optimization of disease control. A comprehensive preoperative ophthalmic assessment for the presence of concomitant ocular pathology, with particular emphasis on macula and optic nerve involvement, is essential to determine which patients will benefit from improved vision after cataract surgery. Meticulous examination in conjunction with adjunct investigations can help in preoperative surgical planning and in determining the need for combined or staged procedures. The eye should be quiescent for a minimum of 3 months before cataract surgery. Perioperative corticosteroid prophylaxis is important to reduce the risk of cystoid macular edema and recurrence of the uveitis. Antimicrobial prophylaxis may also reduce the risk of reactivation in eyes with infectious uveitis. Uveitic cataracts may be surgically demanding due to the presence of synechiae, membranes, and pupil abnormalities that limit access to the cataract. This can be overcome by manual stretching, multiple sphincterotomies or mechanical dilation with pupil dilation devices. In patients <2 years of age and in eyes where the inflammation is poorly controlled, intraocular lens implantation should be deferred. Intensive local and/or oral steroid prophylaxis should be given postoperatively if indicated. Patients must be monitored closely for disease recurrence, excessive inflammation, raised intraocular pressure, hypotony, and other complications. Complications must be treated aggressively to improve visual rehabilitation. With proper patient selection, improved surgical techniques and optimization of peri- and post-operative care, patients with uveitic cataracts can achieve good visual outcomes.

[Hybrid (femtosecond laser-assisted) phaco surgery and the state of the macula]

The review covers different aspects of the impact of femtosecond laser-assisted cataract surgery on the state of the macular zone of the retina. Literature search has revealed inconsistency of the published data and indicated the need for a more detailed study of this problem.

Femtosecond laser-assisted cataract surgery, technology, outcome, future directions and modern applications

Since its introduction in 2009 femtosecond laser-assisted cataract surgery (FLACS) has promised to revolutionize cataract surgery. Despite its promise, the assessment of FLACS's perceived benefits has proven to be far more complicated than initially might have been thought. Most studies to date have not provided validation of FLACS technology as a clinically significant advancement on our current techniques. We review FLACS technology and outcomes including detailed analysis of safety, efficacy, cost effectiveness and future prospects using data from the literature and our own published clinical experience.

Comparison of the frequency of use of a pupil expansion device with and without an intracameral phenylephrine and ketorolac injection 1%/0.3% at the time of routine cataract surgery

Purpose

The objective of this study is to evaluate whether a phenylephrine and ketorolac injection 1%/0.3% (phenyl/keto injection) (Omidria^®) prior to capsulotomy decreases the need for the Malyugin Ring^® to manage small pupils.

Setting

Bucci Laser Vision Institute, Wilkes-Barre, PA, USA.

Design

Retrospective analysis of cataract surgeries performed by a single surgeon at a single center.

Methods

A historical control group of 1,004 consecutive cases (December 2013 to February 2015) did not receive a phenyl/keto intracameral injection prior to capsulotomy and were compared with 915 consecutive cases in the treatment group (June 2015 to April 2016) for the rate of use of the Malyugin Ring. Epinephrine injections were selectively used in the control group as per surgeon judgment. Use of the femtosecond laser was recorded for both groups. The incidence of alpha-1 blocker patients and the use of the femtosecond laser were recorded for both groups.

Results

In the 1,004 cases performed in the historical control group without a phenyl/keto injection, the surgeon chose to use the Malyugin Ring 79 times (7.87%). In the 915 cases performed in the treatment group, the surgeon chose to use the Malyugin Ring 27 times (2.95%). The surgeon selectively used intracameral injections of epinephrine in the control group 64 times (6.47%). There was no significant difference in the use of the femtosecond laser in the control group (15.04%) versus the treatment group (16.28%); however, 4 (2.65%) femtosecond patients in the control group required a Malyugin Ring, while zero patients needed the ring in the femtosecond treatment group. The incidence of Malyugin Ring use in alpha-1 blocker patients was 12/49 (24.49%) in the control group and 6/49 (12.74%) in the treatment group (P=0.05).

Conclusion

The frequency of use of the Malyugin Ring was significantly reduced (P<0.001) from 7.87% to 2.95% with this treatment. These results strongly suggest that the antimiotic/anti-inflammatory effects of this phenyl/keto injection reduced facility costs, surgical time, and other complexities related to the use of the Malyugin Ring during phacoemulsification.

Current and effective advantages of femto phacoemulsification

PURPOSE OF REVIEW

The purpose is to review the current and effective advantages of femtosecond laser-assisted cataract surgery (FLACS).

RECENT FINDINGS

FLACS has advantages over manual phacoemulsification in its precision, and predictability and may be especially advantageous in difficult situations such as shallow anterior chamber, subluxated cataracts, white cataracts, and so on. However, the femtosecond capsulorhexis may not be as strong as a manual rhexis. Laser-induced miosis is also a potential disadvantage.

SUMMARY

There may be increased surgeon confidence and patient satisfaction with FLACS and it may be friendlier to the internal structures of the eye. However, it is not superior to manual phacoemulsification in terms of primary outcomes such as visual and refractive outcomes or overall complications. Further refinements in technology may be needed to give it distinct advantages over manual phacoemulsification and to make it the norm in cataract surgery.