Home > News > Femtosecond Laser-assisted Cataract Surgery— Challenging Cases, Successes, and Complications
Anterior Segment, Cataract Surgery
Read Time: 4 mins

Femtosecond Laser-assisted Cataract Surgery— Challenging Cases, Successes, and Complications

Published Online: March 20th 2015 US Ophthalmic Review, 2015;8(1):19–20 DOI: http://doi.org/10.17925/usor.2015.8.1.19
Authors: Mark Packer
Quick Links:
Abstract
Article
Article Information
Abstract:
Overview

While femtosecond laser-assisted cataract surgery (FLACS) is evolving as an alternative to phacoemulsification, there are a lack of data on its use in challenging cases. This article discusses cases in which FLACS is particularly advantageous including subluxated cataracts, prior eye surgery, combined vitrectomy and FLACS, pediatric cataract surgery, small pupils, and nanophthalmos. However, FLACS does not produce superior outcomes in all cases and caution is needed in cases of posterior polar cataracts, glaucoma, and prior use of silicone oil.

Keywords

FLACS, challenging cases, complications

Article:

The last few years have seen a deluge of publications discussing the potential advantages of femtosecond laser-assisted cataract surgery (FLACS) compared with traditional phacoemulsification, but its introduction has been controversial. While many consider that the technique will transform cataract surgery, others claim it is not cost-effective and offers no significant advantages over traditional techniques. In routine cases, FLACS has been shown to be comparable or superior to manual phacoemulsification.1,2 On the other hand, in difficult and challenging cases, FLACS may offer new opportunities for success. The quality of the capsulotomies associated with FLACS,3 together with the reduction in the time and energy required for ultrasound fragmentation of the cataract,4 suggest that the technique may be of value in high-risk, complex clinical cases. However, the major clinical trials investigating the efficacy and safety of FLACS have had strict exclusion criteria, and details of its use in challenging cases have only recently begun to emerge. This review discusses areas of promise as well as cases requiring caution.

FLACS has been associated with decreased endothelial cell loss,5 an important consideration in cataract surgery after corneal transplant because postoperative transplant cell counts are lower than those of normal corneas. FLACS has been successfully applied to an eye that had a previous penetrating corneal transplant,6 and may be beneficial in other conditions causing low preoperative endothelial cell values or at higher risk for endothelial cell loss (e.g. endothelial dystrophy, diabetes, the elderly).

Questions have been raised about the safety of FLACS in patients that have had prior surgery. Cataract surgery in an eye that has had a prior vitrectomy can be challenging because the absence of the vitreous can lead to anatomic abnormalities, such as a deep anterior chamber and less support of the crystalline lens. Vitrectomy and concurrent FLACS is a safe and effective procedure that offers advantages compared with conventional procedures.7,8 Prior refractive surgery, including laserassisted in situ keratomileusis (LASIK) and radial keratotomy (RK), has not been associated with any flap complications or wound leak in FLACS.9,10

Pediatric cataract surgery has a relatively high rate of complications, partly due to the elasticity of the capsule in young eyes. However, the femtosecond laser has potential to perform a circular, well-centered capsulotomy in these cases, and researchers in Germany have successfully performed FLACS anterior and posterior capsulotomies on infants.11 In another instance of likely capsular complications, FLACS anterior capsulotomy with adjunctive use of a modified capsular tension ring has succeeded in a child with Marfan syndrome.12

Cataracts resulting from trauma present significant challenges to the ophthalmic surgeon. Cataract surgery in white or hypermature cataracts has been associated with increased risk for incomplete capsulorhexis, posterior capsule rupture, endothelial cell loss, and incision complications, such as wound burn.7 FLACS has been successfully employed in cases of dense, white cataracts and cataracts following trauma.13 Subluxated cataracts are also challenging, and traditional phacoemulsification requires the use of various types of endocapsular and fixated capsular tension devices. A case of successful application of FLACS to a subluxated traumatic cataract has recently been described.14

Cases of small pupils initially presented a challenge for surgeons performing FLACS because the pupil must be able to dilate sufficiently to make an adequately sized capsulotomy. The application of laser energy may decrease pupil size by around 30 %,15 potentially risking damage to the pupillary border by laser application during the treatment. However, mechanical dilation devices such as the Malyugin Ring® (Redmond, WA, US) have successfully been used been used for small pupil in different settings.16 A case has been reported of successful use of FLACS following mechanical dilation of the pupil with a Malyugin Ring in a patient with an irregular, small stuck-down pupil.17 In addition, the presence of a small pupil can also be managed by applying intracameral mydriatics, and FLACS has achieved good outcomes in these patients.18,19

Nanophthalmic eyes have worse refractive predictability and postoperative outcomes compared with relative anterior microphthalmos eyes and normal eyes.20 FLACS has been successfully performed in a nanopthalmic eye.21

Despite all these successes, FLACS does not provide superior outcomes in all cases. In a recent study, two patients with bilateral, visually significant posterior polar cataracts underwent traditional phacoemulsification in one eye and FLACS in the fellow eye. In both cases, the eye treated with FLACS developed a posterior capsule rupture during lens removal; one eye also retained nuclear fragments (see Figure 1). Visual outcome was excellent in both eyes of both patients, but this study suggests that traditional phacoemulsification with extensive hydrodelineation and viscodissection of cortex should remain the preferred treatment option for posterior polar cataracts.22

Caution may also be needed in the use of FLACS in glaucoma. A recent study found that femtosecond pretreatment of cataract caused a greater transient rise in intraocular pressure (IOP) after treatment and a higher residual IOP after vacuum undocking in glaucomatous eyes than in nonglaucomatous eyes. The long-term implications of these findings are not known and further studies are needed.23 However, FLACS can also successfully be used in certain cases of phacomorphic glaucoma, though mechanical pupil dilation may be needed.24

Silicone oil has been used for decades in retinal surgery, and two cases of FLACS were recently reported following previous retinal-detachment repair using silicone oil that was subsequently removed. The presence of silicone oil in the anterior chamber prevented delivery of the femtosecond laser treatment through the affected area, resulting in incomplete capsulotomy and lens fragmentation in both cases. Because silicone oil has a lower density than aqueous and migrates superiorly, it will be necessary to carefully evaluate for the presence of silicone oil in eyes having FLACS after a vitrectomy with silicone-oil endotamponade.25

The use of femtosecond lasers in cataract surgery is continuing to evolve, together with its potential applications. In conclusion, as techniques and technology progress, we look forward to finding new opportunities for success with FLACS, while avoiding pitfalls by heeding cautionary signs.

Article Information:
Disclosure

Mark Packer, MD, FACS, CPI, is a consultant to Alcon Laboratories (Novartis AG) and Bausch & Lomb (Valeant Pharmaceuticals International, Inc.), and is consultant to and has equity in Lensar, Inc.

Correspondence

Mark Packer, MD, FACS, CPI, 1400 Bluebell Ave, Boulder, Colorado, US. E: mark@markpackerconsulting.com

Support

Editorial assistance was provided by Katrina Mountfort, PhD, from Touch Medical Media, London, UK, funded by Touch Medial Media.

Access

This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Received

2015-02-17T00:00:00

References

  1. Abell RG, Darian-Smith E, Kan JB, et al., Femtosecond laserassisted cataract surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single center, J Cataract Refract Surg, 2015;41:47–52.
  2. Chen H, Hyatt Y, Afshari NA, et al, Femtosecond laser cataract surgery versus phacoemulsification: a meta-analysis of visual and refractive outcomes, presented at ARVO 2014, Orlando, Florida; Abstract no A0210.
  3. Mastropasqua L, Toto L, Calienno R, et al., Scanning electron microscopy evaluation of capsulorhexis in femtosecond laserassisted cataract surgery, J Cataract Refract Surg, 2013;39:1581–6.
  4. 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;39:1297–306.
  5. Conrad-Hengerer I, Al Juburi M, Schultz T, et al., Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser-assisted cataract surgery: three-month follow-up, J Cataract Refract Surg, 2013;39:1307–13.
  6. Nagy ZZ, Takacs AI, Filkorn T, et al., Laser refractive cataract surgery with a femtosecond laser after penetrating keratoplasty: case report, J Refract Surg, 2013;29:8.
  7. Bali SJ, Hodge C, Chen S, et al., Femtosecond laser assisted cataract surgery in phacovitrectomy, Graefes Arch Clin Exp Ophthalmol, 2012;250:1549–51.
  8. Gomez-Resa M, Nieto I, Corcostegui B, Combined 23-gauge vitrectomy and femtosecond laser-assisted cataract surgery, Ophthalmic Res, 2014;52:141–6.
  9. McDaniel KPJ, Surgical outcomes of femtosecond laser cataract surgery in post refractive patients. Presented at ARVO 2014, Orlando, Florida; Abtract A0204, 2014.
  10. Assil K, Refractive outcomes following femtosecond laserassisted cataract surgery in post-LASIK Eyes. Poster presented at: International Society of Refractive Surgery (ISRS) Symposium; January 17–20, 2013; New Orleans, LA.
  11. Dick HB, Schultz T, Femtosecond laser-assisted cataract surgery in infants, J Cataract Refract Surg, 2013;39:665–8.
  12. Schultz T, Ezeanosike E, Dick HB, Femtosecond laser-assisted cataract surgery in pediatric Marfan syndrome, J Refract Surg, 2013;29:650–2.
  13. Nagy ZZ, Kranitz K, Takacs A, et al., Intraocular femtosecond laser use in traumatic cataracts following penetrating and blunt trauma, J Refract Surg, 2012;28:151–3.
  14. Grewal DS, Basti S, Singh Grewal SP, Femtosecond laser-assisted cataract surgery in a subluxated traumatic cataract, J Cataract Refract Surg, 2014;40:1239–40.
  15. Jun JH, Hwang KY, Chang SD, et al., Pupil-size alterations induced by photodisruption during femtosecond laser-assisted cataract surgery, J Cataract Refract Surg, 2015;41:278–85.
  16. Dick HB, Schultz T, Laser-assisted cataract surgery in small pupils using mechanical dilation devices, J Refract Surg, 2013;29:858–62.
  17. Roberts TV, Lawless M, Hodge C, Laser-assisted cataract surgery following insertion of a pupil expander for management of complex cataract and small irregular pupil, J Cataract Refract Surg, 2013;39:1921–4.
  18. Conrad-Hengerer I, Hengerer FH, Schultz T, et al., Femtosecond laser-assisted cataract surgery in eyes with a small pupil, J Cataract Refract Surg, 2013;39:1314–20.
  19. Hashemi H, Seyedian MA, Mohammadpour M, Small pupil and cataract surgery, Curr Opin Ophthalmol, 2015;26:3–9.
  20. Jung KI, Yang JW, Lee YC, et al., Cataract surgery in eyes with nanophthalmos and relative anterior microphthalmos, Am J Ophthalmol, 2012;153:1161–8 e1.
  21. Martin AI, Hughes P, Hodge C, First report of femtosecond laser cataract surgery in a nanophthalmic eye, Clin Experiment Ophthalmol, 2014;42:501–2.
  22. Alder BD, Donaldson KE, Comparison of 2 techniques for managing posterior polar cataracts: Traditional phacoemulsification versus femtosecond laser-assisted cataract surgery, J Cataract Refract Surg, 2014;40:2148–51.
  23. Darian-Smith E, Howie AR, Abell RG, et al., Intraocular pressure during femtosecond laser pretreatment: Comparison of glaucomatous eyes and nonglaucomatous eyes, J Cataract Refract Surg, 2015;41:272–7.
  24. Kranitz K, Takacs AI, Gyenes A, et al., Femtosecond laserassisted cataract surgery in management of phacomorphic glaucoma, J Refract Surg, 2013;29:645–8.
  25. Grewal DS, Singh Grewal SP, Basti S, Incomplete femtosecond laser-assisted capsulotomy and lens fragmentation due to emulsified silicone oil in the anterior chamber, J Cataract Refract Surg, 2014;40:2143–7.

Further Resources

Share this Article
Related Content In Cataract Surgery
  • Copied to clipboard!
    accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72