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Cataract Surgery and the LenSx ® Femtosecond Laser System—2015 Update for reference features from the limbus, scleral vessels, and the iris to be used as anatomical landmarks. 3,7 The reference data are transmitted directly to the VERION™ Digital Marker L attached to the laser system to prevent transcription errors. 3,7 The VERION™ Digital Marker L allows for cyclorotation adjustments prior to creating the capsulotomy and incision: this allows the axis position to exactly match the intended location for incisions (see Figure 1). 3,7 Figure 1: The Verion Digital Marker Compensates for Ocular Cyclotorsion to Allow for Precise Alignment of LenSx ® Laser procedures 3 Docking Docking the patient interface has been previously shown to be quick and successful. 2 The LenSx ® Laser system upgrade includes the SoftFit™ Patient Interface, which uses a soft contact lens that more closely matches the corneal curvature and reduces pressure on the eye, 7,8 improving efficiency and eye centration. 6 One study found that when the updated interface was used, there were no reported cases of anterior capsule tear or corneal fold and no additional applanation attempts were required. 9 The SoftFit™ Patient Interface appears to result in lower complications compared with conventional cataract surgery results as well as with the older direct contact interface. 9 The smaller size is also advantageous in small eyes because canthotomy, along with its associated risks, may be avoided. 10 The docking mechanism does not require a suction ring or cup, elements that are more prone to movement and increased risk for suction loss. 11 Shortening the femtosecond laser treatment duration can decrease the likelihood of suction breaks, 12 pupil miosis, and conjunctival redness or hemorrhage. 13 In a recent short case series, the LenSx ® Laser system was shown to have much lower total suction-on time relative to the Catalys* and Victus* femtosecond laser systems. 11 This could be attributed to the combination of the LenSx ® Laser’s high-repetition rate and efficient incision algorithms. 7 Figure 2: The “Frag” Lens Pattern 6 Capsulotomy Studies demonstrate that the vast majority of laser capsulotomies are complete and free-floating. 2,14 Laser capsulotomies have been previously shown to be well centered, more regularly shaped, stronger, with a more precise diameter and positioning as well as better circularity than manual capsulotomies. 2 Recent updates to the LenSx ® Laser system allow more flexibility in automated prepositioning of the capsulotomy. 7 The capsulotomy can be centered over the dilated or undilated pupil, the visual axis, or the center of the limbus. 7 Fragmentation Previous lens fragmentation patterns included radial and cylinder patterns of varying diameters. 7 The newly updated LenSx ® Laser software is now capable of creating a grid fragmentation pattern of segments, called the “frag” pattern (see Figure 2). 7 The advancement allows both size and spacing to be customized to meet the specific demands of a given cataract. 6 Customization is particularly useful for denser cataracts 6 where a greater degree of fragmentation may significantly reduce phacoemulsification energy and time requirements. 7 The estimated time to complete a difficult fragmentation using the new pattern is about 40 to 45 seconds. 3 Phacoemulsification Previous studies have shown that FLACS may decrease phacoemulsification energy, potentially reducing endothelial cell loss and corneal edema U S Oph th a l mic Review when compared with conventional cataract surgery. 15,16 A recent study demonstrated that effective phacoemulsification time and endothelial cell loss were lower in a FLACS-treated group compared with the conventional cataract surgical group: both groups had similar cataract grades and included grade 5 cataracts. 17 Reduced phacoemulsification energy has 11