Laser Assisted Cataract Surgery

Laser Assisted Cataract Surgery: The New Frontier The Joseph H. Wyatt DO Lecture Brian D. Ranelle D.O. Texas Eye and Laser Center Ft. Worth and Hurst, Texas

Laser Assisted Cataract Surgery The New Frontier

The Joseph H. Wyatt Lecture 1972 1962 1957 1958

The Joseph H. Wyatt Lecture 1938 1978 2010

The Joseph H. Wyatt Lecture Dr. Joseph Wyatt and partner Dr. Patrick Murray 1975

The Joseph H. Wyatt DO Lecture 1874 AT Still establishes the Osteopathic Profession 1908 American College of Ophthalmology l and ENT established 1961 First Osteopathic Ophthalmology residency started by Joseph Wyatt DO in Detroit, Michigan 1995 Separate colleges of Ophthalmology and ENT established Dr. Brian D. Ranelle TexasoEye & Laser Center

The Joseph H. Wyatt Lecture Born Feb. 20, 1920 in Flora, Illonis Quarterback and captain of both football and db basketball llt teams Attended Kirksville College Osteo. Med Internship 1943 Detroit Osteo. Hosp. 1946-4848 EENT residency LA, California 1961 Started first ophthalmology residency in Detroit, Mich. Over 100 residents graduated from DOH

Joseph H. Wyatt DO Lecture When you complete your residency you are given the right to tend to patients and treat their eye disease. However, Ophthalmology is a specialty that constantly changes and requires that you keep up or you fall behind.

Laser-Assisted Cataract Surgery 3 million cataract surgeries in U.S. in 2010 78 million baby boomers coming 10,000 baby boomers turn 65 every day Patients ate ts desire e to be gasses glasses independent Patient awareness of Lasers is high Lasik & Intralase are fore-runners runners of Femtosecond Lasers with high acceptance

Laser Assisted Cataract Surgery: Presbyopia Baby Boomers Born 1946-1964, 1964, 78 million Ages 40-65 Disposable income Do not want to look or be old Ophthalmic Needs: Early cataracts Refractive errors Presbyopia Desire to be glasses free

Laser Assisted Cataract Surgery Femtosecond Laser Technology Photodisruption of tissue-cells High speed, ultra short pulses that last one millionth of one billionth of one second High degree of controlled sculpting No collateral damage to adjacent tissue Plasma formation with production of OBL/ bubbles

Optical Delivery System Laser is set to desired depth-lensx Defined distance from bottom of glass applanation surface Patient Interface Pulses delivered in a prescribed pattern creating a horizontal or vertical cleavage plane in the cornea,anterior capsule and lens

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

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

Laser Assisted Cataract Femtosecond Lasers LenSx Intralase Surgery LenSx Dr. Brian D. Ranelle Texas Eye & Laser Center Intralase

Laser Assisted Cataract Surgery Most important innovation in cataract surgery since phacoemulsification(1970 s) and lens Implants (late 1960 s) Technology (LACS) compliments the use of Presbyopic correcting IOL s Advantages of Femtosecond lasers i.e. accuracy, tissue friendly, reproducible etc. Hopes of improving visual out comes

Laser Assisted Cataract Lens Anterior Capsulotomy Surgery

Laser Assisted Capsulotomy Precise every time, watch for tags Size, shape, centration ideal Manual capsulotomy less predictable, less precise Capsulotomy diameter variability laser = 29um manual =339um Better IOL centration/ /p position Dr. Brian D. Ranelle Texas Eye & Laser Center

Capsulotomy

Laser Assisted Cataract Surgery Present visual outcomes for Lasik vs. cataract surgery Cataract-40-50% 20/40 or better UCVA Lasik- 95% 20/20 or better UCVA Introduction of Femtosecond technology bi brings cataract t surgery to a visual level comparable with Lasik except for commorbidities

Laser Assisted Cataract LenSx Capsulotomy Surgery

Laser Assisted Cataract LenSx Precision Incision 3Plane Surgery Dr. Brian D. Ranelle Texas Eye & Laser Center

Laser Microincisional Cataract Surgery Allows small incisions of any size Precise corneal incisions Incisions can be placed anywhere on cornea Can still make manual incisions

Laser Arcuate Incisions for Astigmatism 73% of population has >.50 D of astigmatism 39% has > 1.00D of astigmatism Treat more ATR astigmatism, less WTR astigmatism Avoid flipping i axis Combine arcuates with Toric IOL s

Refractive Accuracy: Addressing Astigmatism TORIC IOL Manual LRI TORIC IOL

Laser Arcuate Nomogram LRI s.50d 1 = 45*.75D 2 = 30* 1.50D 2 = 60* 3.00D 2 = 90* Donnenfeld nomogram LenSx.50D 1 = 30*.75D 2 = 20* 1.50 D 2 = 40* 3.00D 2 = 60* 30% Reduction from LRI nomogram Residual Astigmatism is the most common cause of reduced vision after cataract surgery

Laser Assisted Cataract: Corneal Incisions Primary and secondary incisions more reproducable Arcuate incisions precise Arcuates 80-85% 85% deep Arcuates at 8.5-9mm OZ Open arcuates at surgery or later Improved visual outcomes

Laser Assisted Cataract Surgery: Addressing Astigmatism Arcuate Incisions LenSx Dr. Brian D. Ranelle Texas Eye & Laser Center

Laser Assisted Fragmentation of Lens Breaks up, chops nucleus Easier to remove Less surgical time Select nucleofractious options: Quadrant Cylinder Combination

Laser Assisted Cataract Surgery Laser Lens Chop Dr. Brian D. Ranelle Texas Eye & Laser Center

Lens Fragmentation

Advantages of Laser Assisted Cataract Surgery Excellent control of laser treatment Ability to produce precise and reproducible incisions Accurate placement of IOL post-op op or Effective Lens Position (ELP) Corrects Astigmatism Less refractive and surgical surprises

Laser Assisted Cataract Surgery: Effective Lens Position (ELP) Precise capsulotomy (5mm), no collateral tissue damage Ideal IOL placement in capsular bag Stronger capsulotomy, less tears Goal is Better visual outcomes Especially important with Premium IOL s

Laser Assisted Cataract Surgery: Ultrasound Power Reduced Ultrasound Power/Time 42% reduction in Phaco. Power 50% reduction in Phaco. time Preservation of endothelial l cells Less corneal edema/ corneal thickness

Laser Assisted Cataract Advantages LenSx Surgery

Laser Assisted Cataract Surgery: Advantages Uniform size, centered capsulotomy Reproduceable corneal incisions Arcuate incisions for astigmatism Nucleus removal: Less phaco. power/ time Less post-op op inflammation, with better vision faster IOL position more predictable (ELP)

Three Big Advantages of Laser Cataract Surgery 44% Reduction in Phaco. Power 50% Reduction in Phaco. Time Reduced endotheliai cell loss

Standared Phacoemulsification Most common method of cataract t surgery More ultrasound needed as cataract becomes more dense Excess ultrasound energy problems: corneal edema/ endothelial cell loss wound burns more time with potential ti complications

Standard Phacoemulsification Over 50% increase in ultrasound power Extends phaco. time Increased corneal edema More post-op inflamation

Methods To Reduce Ultrasound Power Ultrasound modulation of energy Torsional phaco Pulse duty cycle Surgical Techniques to reduce power/phaco. time Chopping techniques of lens Viscoelastics

Disadvantages of Laser Assisted Cataract Surgery Post op subconjunctival hemorrhages-mild mild Cost of equipment high Adds time to routine cataract surgery Not reimbursed by medicare/ e/ insurance Not all patients candiates- tight lids, small pupils, p glaucoma, corneal conditions, ARMD Not all patients can be docked

Laser Assisted Cataract Surgery: Other Uses of Laser Corneal surgeries- Transplants, Lamellar Sx Refractive laser/ Intrastromal vision correction Collagen cross-linking for KC / ectasia Sl Scleral l surgery- Glaucoma Surgery Corneal wedge resections etc

Laser Assisted Cataract Surgery: Goals Increased precision / safety Makes cataract surgery more reproducible Surgeon directed, computer controlled Achieve true refractive outcomes comparable to Lasik Will it become the Standard of Care?

Laser Vision Correction: Femtosecond Lasers Laser corneal surgery Lasik corneal flaps Lameller Sx, Wedge resections Laser assisted sted cataract act surgery Clear lens removal/refractive lens exchange Combined with Presbyopic/ Toric IOL s

Beginning Lessons Good Docking is the Key Good lid speculum Proparacaine applied to PI Proper head position Pe Prevent entpoblems Problems Meniscus creep Air bubbles with dock Conjunctival obstruction Lid hitting speculum

Beginning Lessions Learning curve Re-Dock several times for good suction Adjust surgical schedule Laser set-up: Outside OR ideal Avoid complications Ant./Post. Capsule tears Capsule block-gentle hydrodissection If docking not good or capsulotomy poor convert to routine case!

Integration of the Laser in the ASC Space: In ASC between OR s Time: Adds 5 minutes/ case Access: Make it easy for patients/ staff Money: Costs/ Marketing People: Patients/ Staff

Personal Experience with LACS Anterior capsule tears Posterior capsule tears Reduced phaco. time Less post-op op inflammation Faster visual recovery Excellent IOL position Safer than manual technique

Laser assisted cataract surgery raises the bar in vision correction o to a new level. It is customizable, it is more precise and more reproduceable than standard cataract surgery. This will benefit the patient with better visual outcomes and safety. Our patients should see the results with this advanced technology.

Optiwave Refractive Analysis (ORA) (Orange) Customizes cataract surgery with LenSx: LenSx Plus Enhanced wavefront image used Improves accuracy of IOL selection Intraoperative astigmatic correction: Both LRI s and Toric IOL s Refines refractive results for better visual outcomes

Blade-Free Laser Assisted Cataract Surgery Technology has given surgeons choices Surgeons need to give patients choices Ideal for Premium IOL s Achieving greater value in Refractive/Cataract Surgery Dr. Brian D. Ranelle Texas Eye & Laser Center

The New Frontier: Laser Assisted Cataract Surgery Weapon Grade Vision Baby Dr. Brian D. Ranelle Texas Eye & Laser Center

Laser Assisted Video