بسم الله الرحمن الرحيم Art of Perfection: Early Egyptian Experience With Femto Laser-Assisted Cataract Extraction Osama Al Nahrawy, MD Professor of Ophthalmology, Suez Canal University, Egypt. Head of Egyptian Society of Femtolaser Eye Surgeries CEO Cortoba eye and lasik centers, Egypt. ASCRS Symposium and Congress, 25-29 April, 2014, Boston, USA. No financial interest in the Machines and equipment mentioned in this presentation. Email: osanahrawy@gmail.com.

Introduction: Available International Technology

After extensive research in USA, The Egyptian scientist A After extensive research in USA, The Egyptian scientist A. Zowail could have Noble price at 1999. He could define the femtosecond unit of time and start femtochemistry. Thank you very much Zowail وشفاك الله وعافاك

Purpose of Study safely and effectively computed electronic cutting, To show the ability of femtosecond laser to perform, safely and effectively computed electronic cutting, and make corneal incisions, capsulotomies and lens fragmentation for series of cataractous eyes .

Patients and Methods Surgeries were done at Cortoba femtolaser eye surgery center, Cairo, Egypt. I have been the only surgeon. 100 eyes of one hundred with cataracts. Age: avg 56 ± 12 yrs. Males: Females: 1:2. BSCVA Avg 0.1 ± 0.3. IOP Avg. 12 ± 8 mmHg. Corneas were clear from any opacities.

Twelve patients were single eyed (12%). Definition of single eyed patients: Other eye is legally blind (less than 0.3), the better eye is much precious Causes either: amblyopia previous complicated ocular surgery.

Systemic work up : Morbidities were controlled before femto cataract surgery. Preoperative: IOL Master calculations of IOLs. Specular endothelial counts . Pentacam densitometry was measured. Pentacam corneal topography was done.

Peribulbar block anaesthesia Peribulbar block anaesthesia. was used for all eyes either before the femtolaser steps (in 4 eyes) or after (in 96 eyes). System checks were made. Data entry and treatment specifications of the capsulotomy size (5-5.5 mm), energy of the laser (6000-7000 nj), selecting cut pattern (radial plus circular or radial alone). Suction clip was placed and centered. Frequency used was 80KHz. Docking, Online real time OCT alignment, XY centering, anterior capsule marking in 90 and 180 meridia, posterior capsule marking in 90 and180 meridia, defining the anterior and posterior capsule safety zones, Activating the laser to cut, and undocking , all were made.

Docking the patient to the femtolaser machine

On-line spectral domain OCT for treatment planning and markings

Energy settings and Computer Treatment palnning

This is really what we get (the delecious fruit): Computed electronic cutting

In the OR Patients were moved to the theater, sterilized and prepped. Corneal incisions were opened by a spatula. A capsulorhexis forceps was introduced to pull away the free floating capsule. Hydrodissection within the cracks was made and fluid was irrigated under the capsule using minimal amounts of fluid. The phako hand piece and a chopper were used to complete nuclear fragment separation. High vacuum settings with minimal power could complete removing the fragments. A Foldable IOL was implanted. Wound hydration was done.

Results Preoperative assessment Pentacam densitometry to asses cataracat density was done. Nuclear densities ranged from 2+ - 5+ . Endothelial cell count. Ranged between 2400 ± 500 cells/mm ². IOL Master to determine IOL power and type. Pentacam Corneal topography: Forme frust KC in three eyes (3%).

Anaethesia: At the first cases (4 eyes), we were afraid if peribulbar anaesthesia was applied before the femtolaser cutting, it might affect the docking or centration, and so it was applied after the femtolaser steps were made. Getting adapted to the technique, it was applied before the femtolaser, and no technical problems or difficulties occurred. All the technical steps were completed as planned

Corneal incisions. Software version 2.5, the machine was not doing the incisions and we had to make it with the knives. After upgrading the machine with version 2.7, The machine could do the corneal incisions. In 10/100 of cases (10%), there was superior trachomatous pannus, and there was a diificulty in opening the main incision by a spatula. A keratome 2.2 was used to open it. The side port incisions were opened easily in 80% of cases Limbal relaxing incisions in 3 cases

Capsulorhexis: Hydrodissection: In all eyes (100%), the capsuolotomy size was as planned (5-5.5 mm) and was centered. No capsular tears or extensions occurred. It was noticed in all cases that the edge of the capsule cut is thickened (cooked cortex) and this caused some difficulty with hydrodissection. Hydrodissection: Hydrodissection was difficult at the beginning and it was made by inserting the canula inside the radial cuts. Hydrodissection in the usual way under the capsular edge was done and represented some difficulty (cooked cortex).

Nuclear Management Nuclear rotation was found to be difficult at the first cases.. Nuclear fragmentation: according to nuclear density, 4-6 radial cuts and sometimes a circle. Aborted in 2 cases (2%). The phako machine and high vacuum settings were used to hold the nuclear fragments and a chopper to separate them. In Three cases (3%), there were difficulty to separate the fragments due to tough posterior plate. Capsular block occurred in 30 eyes (30%) and was relieved by gently pressing the nuclear fragments posteriorly. Effective phako power and time was reduced in all cases between (30-50%).

Post-operative BSCVA: One week: 0.8 ± 0.2. Next post op days, 2 eyes (2 %) showed mild corneal edema that was improved after 5 days.

Conclusions Femto laser became a valuable tool at the hands of cataract surgeons to reach perfection of performance in cataract extraction and reduction of phaco power. Local peribulbar anaesthesia was used in the first 4 cases, after the femtolaser cutting. After getting adapted to the technique, and to save time, it was applied at the very beginning. In all cases, capsulorhexis was made efficiently and safely as designed on the computer graphics. Nuclear softening by the femtolaser was found greatly helpful in reducing effective phako power and time. Applying a safety zone before the posterior and anterior capsules before cutting, raises the safety markedly.

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