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REVIEW
URRENT C OPINION

Femtosecond cataract surgery: transitioning to laser cataract

Gerard Sutton a,b, Shveta Jindal Bali a, and Chris Hodge a

Purpose of review The introduction of the femtosecond laser to the field of cataract surgery offers many potential benefits. The femtosecond laser is able to perform three important steps in cataract surgery: capsulotomy, lens fragmentation and corneal incisions. Although evidence in support of its efficacy is accumulating, there is a surgical learning curve that needs to be addressed. This review outlines key issues to consider when contemplating the transition to laser cataract surgery in clinical practice. Recent findings Laser cataract surgery has been shown to be associated with an initial learning curve. Femtosecond lasers produce a more accurate and precise anterior capsulotomy, improve intraocular lens centration and reduce intraocular lens tilt. Visual and refractive outcomes, although in a limited number of studies, have been shown to be atleast as good as those of conventional phacoemulsification. The impact of reduced phacoemulsification energy on the corneal endothelium is still being investigated. Summary The automation of key steps by the use of femtosecond lasers in cataract surgery has several potential advantages. Emerging literature supports the transition from conventional phacoemulsification to the laser cataract surgery. Keywords capsulotomy, cataract, femtosecond lasers, laser cataract surgery, phacoemulsification

INTRODUCTION
Cataract is responsible for half of the global burden from vision impairment [1,2]. In the western world, phacoemulsification is the surgical procedure of choice routinely providing excellent visual and safety outcomes [37]. Nevertheless, it is not a perfect procedure and room for improvement exists. Complications such as endophthalmitis, cystoid macular oedema, endothelial cell damage, vitreous loss and retinal detachment remain sight threatening concerns [812]. The femtosecond laser is now commercially available to perform three key steps in small incision cataract surgery: capsulotomy, lens fragmentation and wound construction [1315]. This review outlines the clinical reasons for converting to laser cataract surgery (LCS), how to flatten the learning curve and the various logistical issues involved when introducing the procedure to the practice.

of ultrashort pulsed light energy with enough peak power to create plasma. The focused femtosecond pulses induce optical breakdown with significantly less pulse energy, thereby minimizing collateral damage [16,17]. The laser beam characteristics differ for corneal and lens application with respect to the numerical aperture, that is the ratio of the focal length to the diameter of the focusing lens. As compared with corneal refractive procedures, lens manipulations require lasers to focus on a larger target volume and have a deeper penetration. This is accomplished by using a lower numerical aperture, which results in a larger focal spot size. Due to the increase in spot

Vision Eye Institute, Chatswood and bSave Sight Institute, Discipline of Ophthalmology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia Correspondence to Professor Gerard Sutton, MBBS, MS, Vision Eye Institute, Level 3, 270 Victoria Avenue, Chatswood 2067, NSW, Australia. E-mail: gerard.sutton@vgaustralia.com Curr Opin Ophthalmol 2012, 23:000000 DOI:10.1097/ICU.0b013e32835a936b

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HOW DOES THE FEMTOSECOND LASER WORK IN CATARACT SURGERY?

Femtosecond lasers work on the principle of photodisruption brought about by a tightly focused beam

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KEY POINTS
 Femtosecond cataract surgery is a viable alternative to manual phacoemulsification.  Familiarization with the docking system will flatten the learning curve.  Capsular block syndrome can be readily avoided if minor adjustments to the surgical technique are adhered to.

size and strong scattering losses inside the sclerotic crystalline lens, the pulse energy needs to be increased by a factor of 510 to cause photodisruption of the lenticular tissue. In addition, due to variable anatomy of the anterior segment, it is essential to have an imaging system capable of guiding the laser in order to maintain an adequate margin of safety relative to the posterior capsule. At present, four femtosecond laser systems are commercially available for cataract surgery: LenSx (Alcon LenSx, Ft Worth, Texas, USA), OptiMedica (OptimedicaCatalys, Santa Clara, California, USA), Victus (Technolas GMBH Munich, Germany) and LensAR (LensAR Inc. Orlando, Florida, USA). Variations in docking and imaging form the most significant differences between these systems. LenSx was the first commercially available system for LCS. It uses a disposable curved patient interface for docking and live optical coherence tomography (OCT) imaging. This has been approved by the U.S. Food and Drug Administration (FDA) for constructing corneal incisions, anterior capsulotomy as well as lens fragmentation. Optimedica utilizes a fluid-filled interface and spectral domain OCT imaging. LensAR also uses a fluid-filled interface, but the imaging is based on Scheimpflug principle. It has two separately packaged parts to deliver laser energy: a commercially available suction ring with spring loaded syringe to fixate the eye and an index matching eye docking to match refractive index of the cornea and optimize beam targeting accuracy. Currently, both devices have obtained FDA approval for anterior capsulotomy and lens fragmentation. Victus, with a curved AQ3 pressure sensing interface, has CE approval for corneal incisions, anterior capsulotomy, lens fragmentation and refractive procedures.

then docked to the patients eye under topical anaesthesia. Sensors in the delivery system detect the objectives position and applanation force, which is indicated on the screen. After correcting the centration to the limbal landmarks, anterior capsular offset, lens offset, corneal thickness and wound tunnel lengths are selected on a live microscopic OCT image. This is followed by delivery of the laser energy, which can be stopped at any point by releasing the footswitch. The procedure is performed in a sequence of capsulotomy; lens fragmentation; primary and secondary corneal incisions; and arcuate keratotomy. After the completion of the laser procedure, the patient is shifted to the operating room. The laser-created corneal incisions are opened under strict surgical asepsis. Further steps follow as per conventional phacoemulsification with careful removal of the capsulotomy button and lens fragmentation under viscoelastic cover.

IS THERE ANY EVIDENCE THAT IT IS SUPERIOR TO STANDARD SURGERY?

Current research suggests that the use of femtosecond lasers in cataract surgery will provide selective benefits both for the surgeon and the patient; however, there remains little if any evidence that LCS provides superior safety or visual outcomes as compared with conventional phacoemulsification.

Learning curve
Previously, we have shown that there is a learning curve for LCS, which may initially lead to an increased complication rate. This was moderately exaggerated in surgeons not familiar with the use and limitations of a femtosecond laser [18 ,19,20]. Our follow-up data suggest that the learning curve is relatively short, and once overcome, the safety outcomes are comparable, if not better, than standard phacoemulsification surgery (T.V. Roberts, M. Lawless, S.J. Bali, et al., in preparation). Increased surgeon awareness, improved training techniques and continuing development of company software have contributed to the flattening of the curve.
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Anterior capsulotomy
Although clinically we are yet to demonstrate superior outcomes, the laser has definite advantages to standard surgery in some areas. It produces a demonstrably more precise capsulotomy with respect to size and centration [21,22]. Friedman et al. [21] found that the deviation from intended diameter for the resected capsular button was
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THE PROCEDURE (ALCON LenSx)

The initial steps during LCS involve programming the lens, capsulotomy, primary corneal incision, secondary corneal incision and astigmatic keratotomy, if needed. A disposable patient interface is
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29 26 mm for the laser technique and 337 258 mm for the manual technique. As would be expected, an accurate capsulotomy with the femtosecond laser has been shown to result in better intraocular lens (IOL)anterior capsule overlap and hence better IOL positioning [21]. Femtosecond laser capsulotomy has also been demonstrated to produce less IOL tilt and decentration as compared with manual continuous curvilinear capsulorhexis (CCC) [23,24]. In this study, the authors noted that manifest refraction values correlated with total IOL decentration during the postoperative period. Other groups have also reported a more accurate effective lens position and tighter refractive outcomes with LCS [25 ]. Extrapolating these data suggests that LCS may provide superior refractive outcomes by providing a more stable anteroposterior and central IOL position. This may hold special significance for premium IOLs, which are often implanted in patients who demand a near-perfect vision [2628].
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and architecture of the incision tract. Masket et al. [32] have shown, although in cadaver eyes, that manually created incisions are more deformable under pressure and hence may potentially result in more leakage after cataract surgery. Femtosecond-created incisions are more reproducible and stable. But there is no in-vivo evidence that this translates into lower leak rates or lower rates of endophthalmitis. Femtosecond lasers also have the ability to produce very accurate corneal relaxing incisions [33,34]. The advantage of having these lasers to perform quality intraoperative relaxing incisions to reduce preexisting astigmatism or counteract induced cylinder is a potentially significant benefit. Literature suggests that between 9 and 30% of IOLs will rotate by 5 or more degrees by 12 months [35,36]. As IOL rotation effectively reduces the power of the toric correction, the use of laser-created incisions may provide a more stable and accurate result over the use of toric IOLs for some astigmatic patients.

Laser lens fragmentation

There are few published studies at this point that report reduced ultrasonic energy utilization after laser lens fragmentation. Palanker et al. [29] published one of the first series of cases undergoing LCS. It was found that laser lens fragmentation decreased the perceived hardness of the nuclear cataract during phacoemulsification. They also reported a 39% reduction in the cumulative dispersed energy in laser cut lenses as compared with the manual cohort. In another initial study on the use of femtosecond lasers in cataract surgery, Nagy et al. [30] have also reported that using this surgical technique for lens fragmentation reduces the effective ultrasonic energy and time as compared with routine phacoemulsification surgery. Whether these factors result in lower rate of endothelial cell loss has not cs et al. [31] compared central been proven. Taka corneal thickness and endothelial cell counts in eyes undergoing LCS and conventional phacoemulsification. Their results showed that femtosecond laser-assisted cataract surgery caused less corneal swelling in the early postoperative period and this may be related to less trauma caused to corneal endothelial cells. However, no differences were evident between the groups at later postoperative follow-up examinations.

Visual and refractive outcomes

Mihaltz et al. [37] published results of a prospective study comparing 48 eyes that underwent femtosecond capsulotomy and 51 eyes that underwent CCC. The authors noted fewer internal aberrations with femtosecond capsulotomy but no significant difference in uncorrected and corrected distance visual acuities between the groups. In a recent prospective randomized trial consisting of 20 eyes with laser capsulotomy and 25 eyes undergoing nitz et al. [23] noted that femtosecond laser CCC, Kra capsulotomies resulted in better corrected distance visual acuity than their manual phacoemulsification cohort. We analysed the visual and refractive results of the initial 129 eyes that underwent LCS and receiving an aspheric monofocal implant (Acrysof SN60WF, Alcon Laboratories Inc., Texas, USA), and compared the results with a retrospective consecutive cohort that had undergone manual phacoemulsification surgery [38]. The absolute mean difference from the intended spherical equivalent refraction was 0.29 0.25D for the LCS group and 0.31 0.24D for the manual group (P 0.512). Although this difference was not statistically significant, the results remain promising. The LCS group featured an emerging technique without personalized surgeon factors compared with a highly refined manual cohort. In another series of eyes undergoing LCS and multifocal IOL implantation, our group noted that mean spherical equivalent and visual acuity was again comparable with the manual phacoemulsification cohort. The LCS group was
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Corneal incisions
Femtosecond lasers can provide complex and precise corneal incisions. Manual creation of incisions makes it difficult to control the length

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associated with an improved level of unaided visual acuity (unpublished). An interesting analogy for LCS is with the introduction and adaptation of phacoemulsification itself. It was not until 2001 that prospective randomized controlled trials demonstrated beyond doubt the superiority of phacoemulsification over standard extracapsular cataract surgery [3941]; yet, by then it had been adopted by the majority of surgeons in Western countries and their decision to transition was vindicated. It is not an overstatement to suggest that at this time, the surgeons who have moved to LCS have done so with a belief that although it is currently as good as standard surgery, it will eventually provide superior visual and safety outcomes. Time, or perhaps the introduction of similar randomized controlled trials, may again provide the definitive comparison.

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 irrigationaspiration probe under the anterior capsule.

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
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LOGISTICAL ISSUES
The decision to add a femtosecond laser to your existing practice demands a number of important considerations.
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Financial considerations
The laser is an expensive acquisition. Apart from the initial purchase of the laser unit though, the size of the laser requires additional space necessitating renovations to the existing operating room or the use of alternative space within the practice. The equipment will also bring the added costs of repairs, maintenance, insurance and upgrades. Logistically, it is reasonable to assume, at least in the early stages, that the overall surgery time will increase. This will lead either to additional costs for existing staff or a reduction in income due to fewer cases on the surgery list. It is vital therefore that surgeons and administrators have in place a plausible business plan to estimate initial costs, volumes and fees against future projections. On the basis of local estimates, a practice would be required to operate approximately 600 cases in a year to not operate at a loss. This is not practical for all surgeries.

Acknowledgements None. Conflicts of interest No author has received any grants nor has any conflicts of interests relating to the content of the study.

REFERENCES AND RECOMMENDED READING

Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 000000). 1. Pascolini D, Mariotti SP, Pokharel GP, et al. 2002 global update of available data on visual impairment: a compilation of population-based prevalence studies. Ophthalmic Epidemiol 2004; 11:67115. 2. Resnikoff S, Pascolini D, Etyaale D, et al. Global data on visual impairment in the year 2002. Bull World Health Organ 2004; 82:844851. 3. Ong-Tone L, Bell A. Practice patterns of Canadian Ophthalmological Society members in cataract surgery 2009 survey. Can J Ophthalmol 2010; 45:121. 4. Leaming DV. Practice styles and preferences of ASCRS members 2003 survey. J Cataract Refract Surg 2004; 30:892900. 5. Castells X, Comas M, Castilla M, et al. Clinical outcomes and costs of cataract surgery performed by planned ECCE and phacoemulsication. Int Ophthalmol 1998; 22:363367. 6. Riley AF, Malik TY, Grupcheva CN, et al. The Auckland cataract study: co-morbidity, surgical techniques, and clinical outcomes in a public hospital service. Br J Ophthalmol 2002; 86:185190. 7. Murphy C, Tuft SJ, Minassian DC. Refractive error and visual outcome after cataract extraction. J Cataract Refract Surg 2002; 28:6266. 8. Clark A, Morlet N, Ng JQ, et al. Whole population trends in complications of cataract surgery over 22 years in Western Australia. Ophthalmology 2011; 118:10551061. 9. Taban M, Behrens A, Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of the literature. Arch Ophthalmol 2005; 123:613620. 10. Gulkilik G, Kocabora S, Taskapili M, Engin G. Cystoid macular edema after phacoemulsication: risk factors and effect on visual acuity. Can J Ophthalmol 2006; 41:699703. 11. Russell M, Gaskin B, Russell D, Polkinghorne PJ. Pseudophakic retinal detachment after phacoemulsication cataract surgery: ten-year retrospective review. J Cataract Refract Surg 2006; 32:442445. 12. Walkow T, Anders N, Klebe S. Endothelial cell loss after phacoemulsication: relation to preoperative and intraoperative parameters. J Cataract Refract Surg 2000; 26:727732. 13. He L, Sheehy K, Culbertson W. Femtosecond laser-assisted cataract surgery. CurrOpinOphthalmol 2011; 22:4352. 14. Uy HS, Edwards K, Curtis N. Femtosecond phacoemulsication: the business and the medicine. Curr Opin Ophthalmol 2012; 23:3339. 15. Hodge C, Bali SJ, Lawless M, et al. Femtosecond cataract surgery: a review of current literature and the experience from an initial installation. Saudi J Ophthalmol 2011; 26:7378. 16. Chung SH, Mazur E. Surgical applications of femtosecond lasers. J Biophotonics 2009; 2:557572. 17. Sugar A. Ultrafast (femtosecond) laser refractive surgery. Curr Opin Ophthalmol 2002; 13:246249. 18. Bali SJ, Hodge C, Lawless M, et al. Early experience with the & femtosecond laser for cataract surgery. Ophthalmology 2012; 119:891 899. This study outlines a denite learning curve for the use of LCS. Familiarization with the femtosecond laser attens the learning curve. The study suggests that this may be overcome with further laser developments and training. 19. Roberts TV, Sutton G, Lawless MA, et al. Capsular block syndrome associated with femtosecond laser-assisted cataract surgery. J Cataract Refract Surg 2011; 37:20682070. 20. Lawless M, Hodge C. Femtosecond laser cataract surgery: an experience from Australia. Asia-Pacic J Ophthalmol 2012; 1:510. 21. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011; 37:11891198. nitz K, Takacs A, Miha ltz K, et al. Femtosecond laser capsulotomy and 22. Kra manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg 2011; 27:558563. nitz K, Miha ltz K, Sa ndor GL, et al. Intraocular lens tilt and decentration 23. Kra measured by scheimpug camera following manual or femtosecond lasercreated continuous circular capsulotomy. J Refract Surg 2012; 28:259263.

Practice considerations
Surgeries will require different approaches if the laser unit is within or outside the operating theatre and this will determine the patient flow. In our practice, the femtosecond laser was placed outside the operating theatre in a specially designed room. Following the laser ablation, the patients are moved a few metres into the surgery preparation rooms. The initial few cases in our practice saw an increase in the average time for each case; however, this has reduced with experience owing to better patient management and efficient utilization of resources. Currently, the practices with femtosecond technology are likely to be large multisurgeon practices, with or without refractive specialties. As the technology becomes more available and cost-efficient, other smaller practices will be in a position to take on the technology. Although most practices already do surgery well, patient perception of the laser and possible increase in fees will raise the expectations of the patients.

CONCLUSION
Femtosecond cataract surgery is a viable alternative to standard phacoemulsification. It is as safe and effective and has some putative advantages, but clinical superiority is yet to be proven. Awareness of the idiosyncrasies of the femtosecond laser and subtle adjustments to surgical techniques will ensure a relatively flat learning curve and a safe transition for surgeon and patient. Practices will also need to take into account both financial and operational considerations to effectively introduce this technology to patients.

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nitz K, Takacs AI, et al. Comparison of intraocular lens 24. Nagy ZZ, Kra decentration parameters after femtosecond and manual capsulotomies. J Refract Surg 2011; 27:564569. cs I, Taka cs A, et al. Comparison of IOL power calculation 25. Filkorn T, Kova & and refractive outcome after laser refractive cataract surgery with a femtosecond laser versus conventional phacoemulsication. J Refract Surg 2012; 28:540544. This study highlights the potential increase in the predictability of IOL positioning with the use of the femtosecond laser. This may lead to improved refractive results compared with manual phacoemulsication. cs I, Taka cs A, et al. A new intraocular lens design to reduce 26. Filkorn T, Kova spherical aberration of pseudophakic eyes. J Refract Surg 2002; 18:683691. hren J, Kohnen T. Tilt and decentration of spherical and 27. Baumeister M, Bu aspheric intraocular lenses: effect on higher-order aberrations. J Cataract Refract Surg 2009; 35:10061012. 28. Piers PA, Weeber HA, Artal P, Norrby S. Theoretical comparison of aberration-correcting customized and aspheric intraocular lenses. J Refract Surg 2007; 23:374384. 29. Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laserassisted cataract surgery with integrated optical coherence tomography. Sci Transl Med 2010; 2:58ra85. 30. Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009; 25:10531060. cs AI, Kova cs I, Miha ltz K, et al. Central corneal volume and endothelial cell 31. Taka count following femtosecond laser-assisted refractive cataract surgery compared to conventional phacoemulsication. J Refract Surg 2012; 28:387391. 32. Masket S, Sarayba M, Ignacio T, Fram N. Femtosecond laser-assisted cataract incisions: architectural stability and reproducibility. J Cataract Refract Surg 2010; 36:10481049. 33. Nubile M, Carpineto P, Lanzini M, et al. Femtosecond laser arcuate keratotomy for the correction of high astigmatism after keratoplasty. Ophthalmology 2009; 116:10831092. 34. Hoffart L, Proust H, Matonti F, et al. Correction of postkeratoplasty astigmatism by femtosecond laser compared with mechanized astigmatic keratotomy. Am J Ophthalmol 2009; 147:779787; 787. 35. Kwartz J, Edwards K. Evaluation of the long-term rotational stability of single-piece, acrylic intraocular lenses. Br J Ophthalmol 2010; 94:1003 1006. 36. Chang DF. Comparative rotational stability of single-piece open-loop acrylic and plate-haptic silicone toric intraocular lenses. J Cataract Refract Surg 2008; 34:18421847. ltz K, Knorz MC, Alio JL, et al. Internal aberrations and optical quality after 37. Miha femtosecond laser anterior capsulotomy in cataract surgery. J Refract Surg 2011; 27:711716. 38. Roberts TV, Lawless MA, Bali SJ, et al. Femtosecond laser cataract surgery: technology and clinical practice. Clin Experiment Ophthalmol 2012 [Epub ahead of print]. 39. Minassian DC, Rosen P, Dart JK, et al. Extracapsular cataract extraction compared with small incision surgery by phacoemulsication: a randomised trial. Br J Ophthalmol 2001; 85:822829. 40. Katsimpris JM, Petropoulos IK, Apostolakis K, Feretis D. Comparing phacoemulsication and extracapsular cataract extraction in eyes with pseudoexfoliation syndrome, small pupil, and phacodonesis. KlinMonblAugenheilkd 2004; 221:328333. 41. Gogate PM, Kulkarni SR, Krishnaiah S, et al. Safety and efcacy of phacoemulsication compared with manual small-incision cataract surgery by a randomized controlled clinical trial: six-week results. Ophthalmology 2005; 112:869874.

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