White cataracts may be removed with femtosecond layer

[caption id="attachment_6780" align="alignnone" width="750"] FemtoLaser treatment with LenSx - image after docking on white intumescent cataract. Note the extremely flat anterior chamber. Image courtesy of Ozana Moraru MD[/caption]   Using a femtosecond laser may offer a safer means of removing intumescent white cataracts compared to traditional manual phacoemulsification, according to a study presented at the XXXIII Congress of the ESCRS in Barcelona, Spain. “Despite some controversy relating to the high costs of buying and running a femtosecond laser, the device finds its place in difficult cases such as white intumescent cataracts. The greatest advantage of its use is enhanced safety during the capsulotomy step, with a much lower risk for anterior capsule run-out. This minimises the potential risk for further intraoperative complications and eventually for poorer long-term stability and centration of the intraocular lens,” said Ozana Moraru MD. Nevertheless, the technology is not perfect by any means, added Dr Moraru, with ongoing improvements required to further reduce the risk of complications associated with femtosecond laser-assisted cataract surgery (FLACS). Dr Moraru, Medical Director of Oculus Private Eye Clinic, Bucharest, Romania, defined an intumescent white cataract as a completely white lens with a liquefied and under-pressure cortex, no fundus visibility, an anterior chamber depth of less than 2.5mm and a specific A-scan pattern. “These cases have always been challenging for the surgeon. For anterior capsulotomy and continuous curvilinear capsulorhexis (CCC) there is a high risk for single or multiple run-out and irregularities as well as the dreaded ‘Argentinian flag’ sign. There are also associated issues such as flat anterior chamber with little room for manoeuvre, hard brown nucleus underneath, small pupil and high intraocular pressure,” she said. STUDY RESULTS Dr Moraru’s study included 56 eyes of 56 patients aged 42 to 75 operated between March 2014 and March 2015. All eyes were classified as having white, intumescent cataracts with shallow anterior chamber. Manual surgery was performed on 38 eyes, and the remaining 18 patients were treated using FLACS. Primary outcome measures included total surgical time, the difficulty of each surgical step and intraoperative complications. Surgery was generally more difficult in the manual phaco group, said Dr Moraru. “The CCC was more difficult. We always needed to stain the capsule, and sometimes the capsulorhexis was not well centred, or was irregular, or interrupted with a high risk of run-out,” she said. By contrast, the capsulorhexes created by the femtosecond laser were regular and well centred and staining was not always needed. Overall, it was easier, quicker and safer with the femtosecond laser, she said. Complications in the study were all due to the CCC, said Dr Moraru, with seven adverse events in the standard phaco group: three partial rhexis run-outs, three Argentinian flag signs, and one run-out to the periphery. In the femto laser group, two eyes recorded incomplete CCCs that were completed manually. Total surgical time was an average of 12.53 minutes for the standard group and 14.61 minutes for the femtosecond group. “This was mainly due to the docking time of the femtosecond laser, which was prolonged because of difficult fixation. There is a slight learning curve with this in order to do it properly,” she said. FASTER AND SAFER Summing up, Dr Moraru said that the main benefit of the FLACS technique in white intumescent cataracts is the anterior capsulotomy step, which is faster and safer than manual creation. For nucleus division, emulsification and fragment removal there was no difference between the two approaches. Although most of the complications in this series were minor, the risk of potential serious complication after a CCC run-out should not be underestimated, she said. “In our series, the difference between the two techniques for white cataract removal was not significant statistically due to the surgeons’ extensive experience in dealing with intumescent white cataracts in recent years. This explains the low rate of complications in standard phaco in these cases, but would probably be higher for surgeons less accustomed to dealing with such complex cases,” she said. Ozana Moraru: ozana@eye.ro