Revolution of Femtosecond Lasers in Corneal & Cataract Surgery and Beyond

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1 Revolution of Femtosecond Lasers in Corneal & Cataract Surgery and Beyond Ronald R. Krueger, MD, MSE Professor of Ophthalmology Cole Eye Institute Cleveland Clinic I am a consultant for Alcon, and Co-Founder in LensAR What is a Revolution? Its a forcible overthrow of a social order in favor of a new system (or technology)! I am not advocating the overthrow of Opthalmology by Optometry in Eye Surgery.. We co-exist together! What is the Social Order of Eye Surgery? Georg Eisner s Book (1990) outlines the three mechanisms of tissue separation. Cutting is most common, but limited by tissue drag and sectility. The Scalpel 3 Mechanisms of Tissue Separation Cutting Cleaving Ablating Mechanical and Laser Separation Cutting: Sharp dissection (blade) Cleaving: Blunt dissection (wedge) Ablation: Subtractive dissection (laser)

2 Femtosecond Lasers Hit the Ophthalmology Scene ~2002 Femto-Laser Photodisruption 1012 photodisruption Focused laserbeam Intensity [W/cm 2 ] photoablation 100 J/cm² 10 J/cm² 1 J/cm² 0,1 J/cm² vaporisation coagulation photo chemistry fs Interation time [s] 1-3 µm Plasma Shockwave Cavitation bubble Gas bubble Laser Replaces the Blade in Refractive Surgery IntraCorneal Laser Scalpel Hansatome/Moria VS. FemtoLASIK

3 Spectrum of Corneal Femto-Lasers Femtosecond Lasers for Refractive and Corneal Surgery Energy Dependent Mechanisms in Photodisruption Process Femto LDV Technolas Perfect Vision VisuMax 150 khz > 20 MHz 40 khz 500 khz 200 khz fs fs fs fs 350 fs <1uJ >0.03uJ ~1uJ ~0.3uJ >0.3 uj FLAT FLAT Curved Curved FLAT "High" Pulse Energy (µj) "Low" Pulse Frequency (khz) (nj) "Low" Pulse Energy (MHz) "High" Pulse Frequency Today, >70% of U.S. Flaps are with FS Laser Refractive Surgery Alternative Lenticular Extraction Lamellar Lenticule Flap Refractive Flap Replacement & Removal Lift Side Cut Cut

4 Refractive Surgery Alternative Lenticular Extraction Small Incision Lenticular Extraction SMILE LASIK Less Dry Eyes, Stronger Cornea, Closed System Performing a lenticular extraction through a small incision can prevent the creation of a flap, and preserve the strength and nerve supply of the anterior most cornea. Mininally invasive form of LASIK Shaped Corneal Transplants Provides large endothelial surface transplantation Therapeutic Corneal Scalpel - all fs-laser systems

5 Femtosecond Anterior Lamellar Keratoplasty (FALK) Applannation Fluid Bowman s membrane has to be cut! Femto-Assisted Biopsy IntraOcular Laser Scalpel Refractive Laser Assisted Cataract Surgery

6 All-Laser Cataract Surgery All Laser Cataract Surgery 3. Astigmatic Incisions (LRI s) 1. Capsulotomy 4. Self Sealing Cataract Incisions 2. Nuc Frag: Slice and Dice Click to start animation Why Femto Cataract Incisions? Limitations of Manual Surgery Visual Outcomes Distance Correction Predictability Half that of LASIK Safety Complications 1,2 10x LASIK Common Incidence Vision Threatening Incidence Posterior Capsular 10-30% Retinal Detachment % Opacification Cystoid Macular Edema 2-10% Cystoid Macular Edema 1-2% (transient) (persistent) Vitreous Loss 1-5% IOL Malposition 0.3% Corneal Endothelial Cell Loss 4-10% Need for Corneal Transplant 0.3% Endopthalmitis 0.1% 1Pereira et al. JCRS 2006 Oct;32(10): Park et al. Ophthalmic Surg Lasers Imaging Mar-Apr;41(2):236-41

7 Relaxing incisions for astigmatism OCT Image of Femto-Laser Two Plane Corneal Incision Fs Incision Creates Better Sealability Supporting Results from LenSx¹: 0/42 eyes receiving 2 plane laser incision required stromal hydration to seal. 17/18 eyes receiving manual Langerman incision required stromal hydration to seal. Corneal vs. Lens Laser Optics <1 uj <10 uj Limitation with Curved Interface Corneal focusing w/ high NA can treat w/ low energy Lens focusing with low NA requires higher energy Applannation works well in high quality corneal focusing Reflective & compressive losses limit lens focusing

8 Imaging Benefit with Fluid Interface In the same way that immersion ultrasound is better for biometry than contact ultrasound, the fluid filled interface is better for both lens imaging & laser delivery. Imaging and Image-Guided Surgery Contact Fluid Fluid Femto-disruption of Capsule & NS Image Guided Laser Surgery Automated detection of cornea and lens interfaces

9 Femto-disruption of Capsule & NS Imaging Guided Surgery Provides not only localization, but Lens Density Will Allow for Custom Adjustment of Best Energy and Pattern of Laser Fragmentation in the Future Femto-Laser Assisted Capsular Refilling Cataract Surgery Capsular Refilling Techniques for Cataract Surgery with Accommodation Restoration

10 Noninvasive Accommation Restoration with Intralenticular Photodisruption 25 uj/ pulse Total =282 Joules 11.3 M pulses Images 3 years post-treatment AV42 OD Lasered eye D (CARB) 2007 AV42 OS Non-lasered eye 7.25 D (CARB) Ultrashort Pulse Lasers Treating the Crystalline Lens: Will They Cause Vision Threatening Cataract? An AOS Thesis Femtosecond Refractive Index Change

11 Femtosecond Laser photodisruption of the trabecular meshwork for Glaucoma Adaptive Optics Femto-Laser Vitreolysis AO Laser Photodisruption Relaxation of Tissue Traction Gonioscopic delivery of Femtosecond laser pulses is feasible Adaptive Optics Refinement of Femto-Laser Spot Focusing OCT Image Generated during Laser Energy { Visible Bubbling: 2.2 uj to 1.2 uj Hole formation: >3.0 uj to 2.0 uj Adaptive Optics refinement of femtosecond laser focal spot shape through a turbid media (HEMA) in a model eye with photopaper representing the retina.

12 Fs-laser Cell Surgery in DNA enriched Fluid Conclusion Refractive and Corneal surgery has been revolutionized by femtosecond lasers, delivering highly localized, intrastromal cuts with precision greater than any scalpel. As a precision, intraocular cutting tool, the femtosecond laser offers a wide range of new possibilities that will revolutionize modern day ophthalmic surgery. Cost vs. technology benefit will be the new challenge for the future. Remember, With Any Revolution, the Process Changes the Course of History Cole Eye Institute, Cleveland Clinic

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14 Category 1. A well-defined corneal dystrophy in which the gene has been mapped and identified and specific mutations are known. Category 2. A well-defined corneal dystrophy that has been mapped to one or more specific chromosomal loci, but the gene(s) remains to be identified. Category 3: A clinically well-defined corneal dystrophy in which the disorder has not yet been mapped to a chromosomal locus. Category 4. This category is reserved for a suspected new, or previously documented, corneal dystrophy, where the evidence for it being a distinct entity is not yet convincing.

15 Epithelial and subepithelial dystrophies 1. Epithelial basement membrane dystrophy (EBMD) majority degenerative, some C1 2. Epithelial recurrent erosion dystrophies (EREDs) C4 (Franceschetti corneal dystrophy (FRCD) C3, Dystrophia Smolandiensis (DS) C3 and Dystrophia Helsinglandica (DH) C3) 3. Subepithelial mucinous corneal dystrophy (SMCD) C4 4. Meesmann corneal dystrophy (MECD) C1 5. Lisch epithelial corneal dystrophy (LECD) C2 6. Gelatinous drop-like corneal dystrophy (GDLD) C1 Epithelial-stromal TGFBI dystrophies 1. Reis-Bücklers corneal dystrophy (RBCD) granular corneal dystrophy type 3 C1 2. Thiel-Behnke corneal dystrophy (TBCD) C1 3. Lattice corneal dystrophy, type 1 (LCD1) C1-variants (III, IIIA, I/IIIA, IV) of lattice corneal dystrophy C1 Stromal dystrophies 1. Macular corneal dystrophy (MCD) C1 2. Schnyder corneal dystrophy (SCD) C1 3. Congenital stromal corneal dystrophy (CSCD) C1 4. Fleck corneal dystrophy (FCD) C1 5. Posterior amorphous corneal dystrophy (PACD) C1 6. Central cloudy dystrophy of Francois (CCDF) C4

16 7. Pre-Descemet corneal dystrophy (PDCD) C1 or C4 Endothelial dystrophies 1. Fuchs endothelial corneal dystrophy (FECD) C1, C2 or C3 2. Posterior polymorphous corneal dystrophy (PPCD) C1 or C2 3. Congenital hereditary endothelial dystrophy (CHED) C1 4. X-linked endothelial corneal dystrophy (XECD) C2

17 CXL and Excimer Laser Treatment in Ectatic Corneal Disease Bill Tullo, OD, FAAO Ectatic Corneal Disease Keratoconus Definition, Signs, Symptoms, QOL Post-LASIK Ectaisa CXL Mechanism of action Benefits & Limitations Safety & Complications Epithelial and endothelial cell density, keratocyte density, corneal clarity PRK Trans-Epithelial Ablation (T-PRK) Conventional & Optimized Ablations Wavefront guided Excimer Ablations 1 st generation VISX CustomVue, 2 nd generation VISX idesign Topography Guided Ablations B&L development Topography Neutralization Technique -TNT Athens Protocol Wavelight T-CAT US approval & International Experience Nidek EC-5000-Final Fit Planning Software Cone location and potential increased in BDVA CXL T-Cat - ICRS Case 1 - Mild Moderate KC Case 2 Moderate Severe Keratoconus Case 3 Post-LASIK Ectaisa