Femtosecond Laser-Assisted Cataract Surgery (FLACS) MR Jafarinasab MD Labbafinejad Medical Center www.iranophthalex.com

Introduction Having improved outcomes in the field of refractive surgery, beginning with LASIK flap creation, the femtosecond laser is continuing to make great strides across a range of other anterior segment applications, from transplanting corneas and implanting intrastromal rings to perfecting the capsulotomy and blasting cataracts.

Introduction One can't talk about new technology without mentioning femtosecond laser cataract surgery.

Introduction Cataract surgery is one of the most frequently performed surgeries in the world today, enabling millions of people to regain eyesight lost because of cataracts. Modern cataract surgery is safe, effective and highly predictable . Surgical tools and techniques are constantly evolving to make the procedure even better.

Why do we need a Change ? It has been and still is a almost manual that is highly dependent on surgeon Occasionally, even the most experienced surgeon can get an inconsistent surgical maneuvers.

Complications of Traditional PE Cataract surgery complications are still10x that of LASIK LASIK(

Introduction The next major advance in cataract surgery may be the use of femtosecond lasers to perform some of the steps in the cataract procedure

Born of a Workplace Accident The medical use of the femtosecond laser originated more than a decade ago at the University of Michigan in Ann Arbor, in a classic lemons-to-lemonade serendipity: A graduate student in the ultrafast lasers lab had sustained a well-defined laser burn on his retina, according to Shahzad I. Mian, MD, associate professor of ophthalmology and visual sciences at the university. “ The examination of this burn by a second-year resident [Ron M. Kurtz, MD] led to collaborative research between the department of ophthalmology and the school of engineering, and ultimately to the original femtosecond medical laser, marketed as IntraLase in 2001.”

Femtosecond LaserPhotodisruption The laser’s delivery of power pulsed at high speeds generates microscopic gas bubbles that break bonds between cells in a process known as photodisruption

FS Laser Advantages Controllable Laser intensity and Power Precision of Photodisruption Not absorbed by clear media; can be focused Least amount of shock-wave formation Computer-Controlled delicate incisions

Femtosecond Laser Photodisruption Plasma expansion Shock wave pressure Cavitation bubble creation Decreased pulse duration reduces photodisruption threshold and secondary effects allowing closer placement of pulses Initial Beam Cavitation Bubble 11 11

Photodisruption 5 to 12 Microns An expanding bubble of gas & water is created separating the corneal lamellae

Photodisruption The bi-products of photodisruption (CO2 & water) are absorbed by the mechanism of the endothelial pump, leaving a resection plane in the cornea

Photodisruption Thousands of laser pulses are connected together in a raster pattern to define a resection plane

Photodisruption Gas & water are absorbed or liberated when corneal flap is lifted A resection plane is created

Photodisruption Laser pulses can be stacked on each other to create a vertical cleavage plane

Photodisruption Laser pulses can be stacked on each other to create an angled cleavage plane

Spot & Line Spacing The distance from the center of each spot to the one next to & above it can be adjusted Decreasing the distance between spots can ease a smoother lift, but also increase treatment time 10µ Line Spacing Range 8 -14µ 12µ 12µ Spot Spacing

Femtosecond Laser-Assisted Cataract Surgery (FLACS) Objectives: Increase safety Improve precision Automate undependable components

Contemporary Cataract Surgery Steps: Incision Capsulorhexis Phacoemulsification IOL Insertion Relaxing Incisions (Astigmatism)

Cataract Incisions: Wound construction is critical in modern cataract surgery because it is the BASIC step A poorly constructed wound will make subsequent steps more difficult and increase the risk of complications. A well-constructed wound is the first step in successful surgery for both the surgeon and the patient.

Potential Problems in manual Capsulorhexis Small Large Eccentric Irregular

FS Laser-assisted vs Manual Capsulorhexis

FS Laser-assisted vs Manual Capsulorhexis

Femtosecond Laser-Assisted Lens Fragmentation & Softening

Femtosecond Laser-Assisted Lens Fragmentation & Softening

Relaxing Incision for Astigmatism:

Historical Background 2008: First surgery performed by Zoltan Nagy in Budapest using Alcon Lensx Laser 2009: Alcon Lensx became first laser to receive FDA approval for Cataract surgery 2010: First surgery performed in United States performed by Stephen Slade

FS laser cataract surgery procedure Stages of FS laser cataract surgery procedure 1-Planning 2-Engagement (Docking) 3-Visualization and customization 4-Treatment

Docking (Engagement) a patient’s eye must be Prior to delivery of the laser, a patient’s eye must be stabilized relative to the optical system of the laser. In refractive surgery, this is achieved with a curved or flat plate that pulls the eye into a suction ring, distorting the globe In FLACS another option is liquid interface

Visualization and customization The image guidance system is a critical part of laser cataract surgery as it determines the location and dimension of ocular structures It is critical that the posterior surface of the lens ( Posterior Capsule ) be detected in order to maintain a safety zone and prevent cuts in the posterior capsule

Visualization and customization LenSx and OptiMedica use FD-OCT for three- dimensional, high-resolution viewing of ocular structures. LensAR uses a three-dimensional confocal structured illumination- scanning transmitte very similar to Scheimpflug technology . Additionally, the lens density can be valuated

FS Laser-assisted Cataract Surgery Imaging and Registration: OCT Technique (Optimedica) Scheimpflug Technique (LensAR)

Treatment

1. Lensx _ animation 2. lens_aspiration_ii 3. lens_fragmentation_ii 4 1. Lensx _ animation 2. lens_aspiration_ii 3. lens_fragmentation_ii 4. anterior_capsulotomy

FS Laser-Assisted Cataract Surgery: The Future: Sub Bowman’s Relaxing Incisions Complex Cataract Incisions Customized Capsulorhexis Posterior Capsulotomy Capsulorhexis Integrating with IOLs - “Capsule in the Lens” - Toric IOL Orientation IOL Power Adjustment Lens Refilling Surgery

FS Laser-assisted Cataract Surgery: Advantages and Disadvantages: Improved safety Increased precision Enhanced reproducibility Disadvantages: Increased Cost Added time

Conclusion: John A. Vukich, M.D., Madison, Wis., estimated that laser systems would cost anywhere between $400,000 and $550,000. Service fees are about 10% a year of the purchase price. All systems to date have indicated a per use fee of $350-$450 per eye. Dr. Chang ;. “The challenge is that it is very expensive for a procedure we are already doing very efficiently,”

Conclusion: William J. Link, Ph.D., Newport Beach, Calif., when a new technology is introduced, "there's always this beautiful, awkward, disruptive time where we try to sort it out and debate, and then it will be refined with data and experience." Dr. Link believes that in the future, cataract surgery will be dramatically different because of the advent of the femtosecond platform. "For that to happen, it has to work economically, It has to be good for the patient, it has to be good for the practice, it has to be good for the company.

Conclusion: Practices should consider some basic questions: Is it too early? Is it a safe and reliable procedure? Will it provide a benefit to the practice’s patients? Can your facility afford it?

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