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

2. 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.

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

4. 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.

5. 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.

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

7. 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

8. 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.”

9. 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

10. 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

11. 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

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

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

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

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

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

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

18. 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

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

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

21. 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.

22. Potential Problems in manual Capsulorhexis
Small
Large
Eccentric
Irregular

23. FS Laser-assisted vs Manual Capsulorhexis

24. FS Laser-assisted vs Manual Capsulorhexis

25. Femtosecond Laser-Assisted Lens Fragmentation & Softening

26. Femtosecond Laser-Assisted Lens Fragmentation & Softening

27. Relaxing Incision for Astigmatism:

28. 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

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

31. 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

32. 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

33. 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

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

35. Treatment

36. 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

37. 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

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

39. 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,”

40. 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.

41. 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?

42. Thank you