Intraoperative imaging and surgical modifications during femtosecond laser-assisted cataract surgery in a subluxated traumatic cataract

Session Details

Session Title: Femto Cataract II

Session Date/Time: Monday 15/09/2014 | 14:30-16:30

Paper Time: 15:38

Venue: Boulevard B

First Author: : S.Grewal INDIA

Co Author(s): :    S. Basti   D. Grewal           

Abstract Details

Purpose:

The femtosecond laser for cataract surgery may have a potential advantage in cases with severe zonular loss, as it is not dependent on zonular countertraction for continuous-curvilinear-capsulorhexis (CCC) creation, which is among the biggest intraoperative challenges in such cases. We describe a patient with a traumatic subluxated cataract who underwent femtosecond laser assisted cataract surgery and illustrate the utility of intraoperative imaging and the surgical modifications required while highlighting the advantages of the femtosecond cataract laser in such cases.

Setting:

Grewal Eye Institute, Chandigarh, India and Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

Methods:

A 47-year-old male presented with nearly 5 clock hours of zonular dialysis with lens subluxation and a traumatic cataract following blunt ocular trauma. His corrected distance visual acuity was 20/60. There was no vitreous in the anterior chamber and no iridodialysis or angle recession. The posterior capsule appeared intact on slitlamp examination. After discussing the surgical options including the off-label use of the femtosecond cataract laser in such situations, the patient elected to undergo femtosecond laser-assisted cataract surgery. Intraoperative anterior-segment OCT (AS-OCT) confirmed the lens subluxation and an intact posterior capsule. Tilting of the subluxated lens was visualized on AS-OCT and the anatomical landmarks were appropriately adjusted. A 5mm capsulotomy diameter was selected and this was centered using intraoperative imaging on the capsular bag, and, not on the pupil margin¬¬. The custom capsulotomy setting was used to permit free positioning of the capsulotomy within the iris safety zones. The pulse energy was maximized to 10microjoules and the incision depth was 1000microns. Lens fragmentation was performed using the sextant pattern, which comprised of three intersecting lines that fragmented the lens nucleus into six pie cuts. No lens softening was performed and corneal incisions were created manually.

Results:

Intraoperatively, the capsulotomy was found to be complete and free floating. Capsular Support System hooks (FCI Ophthalmics) were used to stabilize and center the capsular bag. Gentle hydrodissection and hydrodilineation were performed taking care to evacuate the cavitation bubbles. The nucleus was then separated along the femtosecond cleavage planes and aspirated with the phacoemulsification probe. A Morcher Capsular Tension Ring (FCI Ophthalmics) was inserted to stabilize the capsular bag and the residual cortex was removed gently with the irrigation-aspiration probe. After confirming the centration of the capsular bag and anterior capsulotomy a three-piece IOL +21.0D, ZA9003 (Abbott Laboratories, Abbott Park, IL) was injected into the capsular bag and was found to center well. Postoperatively the patient did well with a corrected distance visual acuity of 20/20 and a well-centered IOL.

Conclusions:

There are two critical steps for successful cataract surgery in subluxated cataracts: performing a CCC and stabilizing the capsular bag, which cannot be performed without an intact CCC. The risk of further zonular damage and lack of adequate counter-traction make it difficult to perform a manual capsulorhexis in a subluxated lens with zonular loss. The femtosecond laser significantly reduced both these risks and allowed creation of a circular capsulotomy centered on the capsular bag, thus permitting use of capsular support hooks and nuclear removal prior to insertion of the capsular tension ring. Unique to the femtosecond laser was its ability to confirm an intact posterior capsule based on intraoperative imaging, create a capsulotomy centered on the subluxated capsular bag, and fragment the lens in a closed chamber without creating corneal incisions thereby further minimizing intraocular manipulation and zonular stress. These maneuvers help to reduce potential complications in such challenging cases.

Financial Interest:

NONE