Femtosecond Cataract Surgery

Flattening the Surgical Learning Curve

At the time of this review, the author (G.S.) has performed over 250 femtosecond laser procedures. No patient to date has required further treatment due to complications or suffered visual loss. This does not suggest that the introduction of the surgery has not required changes. In our opinion, a few simple precautions and adjustments to surgical technique, and an awareness of the limitations of the femtosecond laser can hasten proficiency and make the transition to LCS relatively painless.

Preoperative Considerations

As with any surgery, appropriate patient selection is vital to ensure the success of the procedure. Excluding patients with the following criteria will serve to reduce the likelihood of encountering additional difficulties:

1. 
   Pupil that will not dilate to 5 mm;
   
2. 
   Corneal opacity precluding the effective translation of laser energy;
   
3. 
   Advanced glaucoma because of the increase in IOP with applanation and suction;
   
4. 
   Uncooperative or overly anxious patients; and
   
5. 
   Small interpalpebral fissures, especially if one is unfamiliar with the docking of a femtosecond laser.
   

Femtosecond Laser Procedure

Docking is paramount to achieving a successful ablation. It is vital to communicate with the patient both the procedure and the impact of their eye position on the surgery. This should be reinforced during the surgery.

As the patient interface is brought down towards the eye, a careful watch for the lid clearance will ensure ease of application to the eye. Access to the eye may be increased by the use of a speculum.

Prior to application, reaffirm the eye position to reduce or avoid eye tilt. Aim to dock centrally to enhance both the position and the interface suction.

The posterior lens fracture should be set at nuclear shadow. It should be ensured that wounds are created at the limbus. In case this is not possible or the wounds seem to be created too centrally, it may be advisable to abort the laser delivery before wounds are created. The incisions may be created manually with keratomes in these cases.

In the Operating Room

Considering the following steps at surgery will reduce the likelihood of intraoperative complications.

1. 
   Ensure that wounds are opened. This may be accomplished with a spatula (Slade spatula) or Utrata forceps.
   
2. 
   Take utmost care to check that the capsule is completely free. There may be micro-adhesions or rarely an area of 'uncut' capsule. Failure to notice this could result in anterior capsular tears, which could radiate to the equator and beyond and result in a dropped nucleus.
   
3. 
   Decompress the anterior chamber prior to hydrodissection to avoid a capsular block syndrome.
   
4. 
   Perform a careful hydrodissection. Consider nuclear split prior to hydrodissection if there appears to be excess intracapsular gas.
   
5. 
   Fragment removal technique should depend on laser programme. We would recommend that surgeons transitioning to this technique should use a four-quadrant pattern with a central circular cut. This allows easy removal of the central core and reproducible nuclear fragmentation.
   
6. 
   It is important to be aware that the cortex may be more difficult to remove because of possible heat adherence to the anterior capsule and the fact that there are fewer tags to remove. We recommend a tangential sweep with the automated irrigation–aspiration probe under the anterior capsule.