G. BAÏKOFF MD, Ch. AUBERT The author is a consultant for Carl Zeiss Meditec Clinique Monticelli – Marseille - France

 The ZEISS VISUMAX ™ FEMTOSECOND LASER obtained the CE mark for corneal grafts in May Graft software has a high frequency pulse rate (200 kHz), with very small spots (2 to 3 µm), the energy delivered is to the scale of the nano Joule  A retrospective study was carried out on 58 eyes having had either MANUAL/MICROKERATOME DSEK (41) or FEMTO DSEK (17).  Over the last 8 months the femtosecond laser has been used for most of the new cases.  Even if the statistic method needs perfecting, analysis of our results reveals a trend

 The Visumax femtosecond laser allows a three dimensional cut of the corneal tissue. Very precise focus, high frequency (200 KHz) and minimum energy enable very smooth cuts due to extremely tight spot spacing (2 - 3 µm).  Deep cuts (up to 800 µm) parallel to the cornea’s epithelial surface give a thin endothelial graft with almost parallel flaps, unlike the microkeratome where depth of cut is rarely more than 350 µm to create a anterior lenticle with thin edges and a thick posterior concave endothelial graft.

MICROKERATOME - MENISCUS CUT - MAXIMUM DEPTH : 200/300 µm DSEK - ALTK VISUMAX FEMTOLASER - PARALLEL CUT - MAXIMUM DEPTH 700 µm NOTICE THE DIFFERENCE OF DONOR’S SHAPE : KERATOME vs FEMTO DSEK - FEMTO

FEMTO DSEKs 1st SURGERY JULY 2008 LAST SURGERY FEBRUARY 2009  CASES 17  MALE 6 FEMALE 11  MEAN AGE 63 RANGE  MEAN F.UP 2.6 months RANGE: 2 weeks – 6 months  PSEUDOPHAKIC CORNEAL OEDEMA : 9  IOL EXCHANGE : 4  FUCHS DYSTROPHY : 5  TRIPLE PROCEDURE (KPE, IOL, DSEK) : 4  NORMAL PREOP MACULA : 4  POSTERIOR POLE PATHOLOGY : 6  UNKNOWN PREOP MACULAR STATUS : 7

MANUAL & MICROKERATOME DSEKs 1st SURGERY NOVEMBER 2007 LAST SURGERY FEBRUARY 2009  CASES 41  MALE 18 FEMALE 23  MEAN AGE 72 RANGE  MEAN F.UP 3.4 months RANGE 2 weeks – 14 months  PSEUDOPHAKIC CORNEAL OEDEMA : 18  IOL EXCHANGE : 6  FUCHS DYSTROPHY : 19  TRIPLE PROCEDURE (KPE, IOL, DSEK) : 14  NORMAL PREOP MACULA : 12  POSTERIOR POLE PATHOLOGY : 7  UNKNOWN PREOP MACULAR STATUS : 22

DAY 1 RECIPIENT 631 µm ENDOTH. 163 µm DAY 7 RECIPIENT 536 µm ENDOTH. 134 µm RECIPIENT 536 µm ENDOTH. 134 µm DAY 60 RECIPIENT 460 µm RECIPIENT 460 µm ENDOTH. 83 µm ENDOTH. 83 µm RECOVERY OF ENDOTHELIUM FUNCTION

ENDOTHELIUM CELL COUNT FEMTO vs MANUAL ENDOTHELIAL C. DENSITY 34 MANUAL DSEK : 1389 C / mm² 34 MANUAL DSEK : 1389 C / mm² 9 FEMTO DSEK : 1738 C / mm² 9 FEMTO DSEK : 1738 C / mm² AVERAGE GRAFT THICKNESS 34 MANUAL DSEK : 155 µm 34 MANUAL DSEK : 155 µm 9 FEMTO DSEK : 103 µm 9 FEMTO DSEK : 103 µm (excluding the 1st case) RECOVERY OF ENDOTHELIUM FUNCTION 9 FEMTO vs 34 MANUAL/KERATOME - 3MONTHS F.UP - - 3MONTHS F.UP - STROMA & DONOR THICKNESS

ADVANTAGES PRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITY PRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITY REGULAR GRAFT : SHAPE-THICKNESS REGULAR GRAFT : SHAPE-THICKNESS WIDE CHOICE OF SETTINGS WIDE CHOICE OF SETTINGS SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT DISSECTION SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT DISSECTION LESS ENDOTHELIAL CELL LOSS LESS ENDOTHELIAL CELL LOSS ADVANTAGES PRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITY PRECISION CUT : DEPTH, DIAMETRE, REPRODUCIBILITY REGULAR GRAFT : SHAPE-THICKNESS REGULAR GRAFT : SHAPE-THICKNESS WIDE CHOICE OF SETTINGS WIDE CHOICE OF SETTINGS SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT DISSECTION SECURITY : REDUCED RISKS OF ERROR ON DONOR GRAFT DISSECTION LESS ENDOTHELIAL CELL LOSS LESS ENDOTHELIAL CELL LOSS DISADVANTAGES COSTLY INVESTISSEMENT COSTLY INVESTISSEMENT SURGERY TIME LENGTHENED (TRAINING LEARNING CURVE) SURGERY TIME LENGTHENED (TRAINING LEARNING CURVE) DEPTH LIMITED BY MINIMUM THICKNESS OF THE CORNEA DEPTH LIMITED BY MINIMUM THICKNESS OF THE CORNEA PRESENTLY ONLY EPITHELIUM PARALLEL CUTS, IMPOSSIBLE TO MATCH THE CUT WITH THE POSTERIOR PLANE (FLEX?) PRESENTLY ONLY EPITHELIUM PARALLEL CUTS, IMPOSSIBLE TO MATCH THE CUT WITH THE POSTERIOR PLANE (FLEX?)

THE ANATOMICAL RESULTS LOOK VERY SATISFYING IN FAVOR OF THE FEMTO DSEK; BUT WE ALSO HAVE TO CONSIDER THE FUNCTIONAL RESULTS. IN OUR TRIALS, THE 3 MONTHS BEST CORRECTED VISUAL ACUITY IS MUCH BETTER IN THE MANUAL/MICROKERATOME DESK SERIES: 0,38 vs 0,12 0,38 vs 0,12!!!!! LONGER FOLLOW UP AND FURTHER TRIALS ARE MANDATORY.