Laser Assisted Cataract Surgery

(1)

Laser Assisted Cataract

S

Th N

F

ti

S

Th N

F

ti

Surgery: The New Frontier

The Joseph H

The Joseph H WyattWyatt DO LectureDO Lecture The Joseph H.

The Joseph H. Wyatt Wyatt DO LectureDO Lecture

Brian D Ranelle D O Brian D Ranelle D O Brian D. Ranelle D.O. Brian D. Ranelle D.O.

T E d L C

Texas Eye and Laser Center Texas Eye and Laser Center Ft. Worth and Hurst, Texas Ft. Worth and Hurst, Texas

(2)

Laser Assisted Cataract

Surgery

The New Frontier Frontier

Dr. Brian D. Ranelle Texas Eye & Laser Center Dr. Brian D. Ranelle Texas Eye & Laser Center

(3)

The Joseph H. Wyatt

p

y

Lecture

1972 1962

1957 ₁₉₅₈

(4)

The Joseph H. Wyatt

p

y

Lecture

1938

2010

1978

(5)

The Joseph H. Wyatt

p

y

Lecture

Dr. Joseph Wyatt and

partner Dr. Patrick p

Murray 1975

(6)

The Joseph H. Wyatt DO

p

y

Lecture

ll bl h h h ll bl h h h



 1874 AT Still establishes the Osteopathic 1874 AT Still establishes the Osteopathic

Profession Profession

1908 A i C ll f O hth l l 1908 A i C ll f O hth l l



 1908 American College of Ophthalmology 1908 American College of Ophthalmology

and ENT established and ENT established

1961 First Osteopathic Ophthalmology 1961 First Osteopathic Ophthalmology



 1961 First Osteopathic Ophthalmology 1961 First Osteopathic Ophthalmology

residency started by Joseph Wyatt DO in residency started by Joseph Wyatt DO in Detroit Michigan

Detroit Michigan Detroit, Michigan Detroit, Michigan



 1995 Separate colleges of 1995 Separate colleges of

Ophthalmology and ENT established Ophthalmology and ENT established Ophthalmology and ENT established Ophthalmology and ENT established

Dr. Brian D. Ranelle

(7)

The Joseph H. Wyatt

p

y

Lecture

b l

b l llll



 Born Feb. 20, 1920 in Flora, Born Feb. 20, 1920 in Flora, IllonisIllonis 

 Quarterback and captain of both football Quarterback and captain of both football

d b k tb ll t d b k tb ll t

and basketball teams and basketball teams



 Attended Kirksville College Attended Kirksville College OsteoOsteo. Med. Med 

 Internship 1943 Detroit Internship 1943 Detroit OsteoOsteo. Hosp.. Hosp. 

 19461946--48 EENT residency LA, California48 EENT residency LA, California 

 1961 Started first ophthalmology residency 1961 Started first ophthalmology residency

in Detroit, Mich. in Detroit, Mich.



 Over 100 residents graduated from DOH Over 100 residents graduated from DOH

(8)

Joseph H. Wyatt DO

p

y

Lecture

“ When you complete your residency “ When you complete your residency you are given the right to tend to

you are given the right to tend to

y g g

patients and treat their eye disease. patients and treat their eye disease. However, Ophthalmology is a specialty

However, Ophthalmology is a specialty, p, p gygy pp yy

that constantly changes and requires that constantly changes and requires that you keep up or you fall behind ” that you keep up or you fall behind ” that you keep up or you fall behind. that you keep up or you fall behind.

(9)

Laser

Laser--Assisted Cataract

Assisted Cataract

Surgery



 3 million cataract surgeries in U.S. in 20103 million cataract surgeries in U.S. in 2010 

 78 million baby boomers coming78 million baby boomers comingyy gg 

 10,000 baby boomers turn 65 every day 10,000 baby boomers turn 65 every day 

 Patients desire to be glasses independentPatients desire to be glasses independentat e ts des e to be g asses depe de tat e ts des e to be g asses depe de t 

 Patient awareness of Lasers is highPatient awareness of Lasers is high 

 Lasik &Lasik & IntralaseIntralase are foreare fore--runners ofrunners of 

 Lasik & Lasik & IntralaseIntralase are foreare fore runners of runners of

Femtosecond

Femtosecond Lasers with high acceptanceLasers with high acceptance

(10)

Laser Assisted Cataract

Surgery:

Surgery: Presbyopia

Presbyopia



 Baby BoomersBaby Boomers

Born 1946

Born 1946--1964, 78 million1964, 78 million A 40 A 40 6565 Ages 40 Ages 40--6565 Disposable income Disposable income

Do not want to look or be old Do not want to look or be old Do not want to look or be old Do not want to look or be old



 Ophthalmic Needs:Ophthalmic Needs:

Early cataracts Early cataractsyy Refractive errors Refractive errors Presbyopia Presbyopia

Desire to be glasses free Desire to be glasses free

(11)

Laser Assisted Cataract

Surgery

Femtosecond

Femtosecond Laser TechnologyLaser Technology



 PhotodisruptionPhotodisruption of tissuepp of tissue--cellscells 

 High speed, ultra short pulses that last one High speed, ultra short pulses that last one

millionth of one billionth of one second millionth of one billionth of one second



 High degree of controlled sculptingHigh degree of controlled sculpting 

 No collateral damage to adjacent tissueNo collateral damage to adjacent tissuegg jj 

 Plasma formation with production of OBL/Plasma formation with production of OBL/

bubbles bubbles bubbles bubbles

(12)

Optical Delivery System



 Laser is set to desired Laser is set to desired

d th

d th L SL S depth

depth--LenSxLenSx

–– Defined distance from Defined distance from bottom of glass

bottom of glass applanationapplanation bottom of glass

bottom of glass applanationapplanation surface

surface –– Patient InterfacePatient Interface

Pulses delivered in a Pulses delivered in a



 Pulses delivered in a Pulses delivered in a

prescribed pattern creating a prescribed pattern creating a horizontal or vertical

horizontal or vertical horizontal or vertical horizontal or vertical cleavage plane in the cleavage plane in the cornea,anterior

cornea,anterior capsule andcapsule and

cornea,anterior

cornea,anterior capsule and capsule and lens

(13)

Photodisruption

pppp

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

(14)

Photodisruption

pppp

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

(15)

Laser Assisted Cataract

Surgery

Femtosecond Lasers L S LenSx Intralase Dr. Brian D. Ranelle Dr. Brian D. Ranelle Texas Eye & Laser Center Texas Eye & Laser Center

LenSx

(16)

Laser Assisted Cataract Surgery



 Most important innovation in cataract Most important innovation in cataract

surgery since

surgery since phacoemulsificationphacoemulsification(1970’s) (1970’s) and lens Implants (late 1960’s)

and lens Implants (late 1960’s)



 Technology (LACS) compliments the use of Technology (LACS) compliments the use of

P b i

P b i ii IOL’IOL’ Presbyopic

Presbyopic correcting IOL’scorrecting IOL’s



 Advantages of Advantages of FemtosecondFemtosecond lasers i.e. lasers i.e.

ti f i dl d ibl t ti f i dl d ibl t accuracy, tissue friendly, reproducible etc. accuracy, tissue friendly, reproducible etc.



 Hopes of improving visual out comes Hopes of improving visual out comes

(17)

Laser Assisted Cataract

Surgery

Lens Anterior Capsulotomy

(18)

Laser Assisted

Capsulotomy



 Precise every time, watch for tagsPrecise every time, watch for tags



 Size shapeSize shape centrationcentration idealideal



 Size, shape, Size, shape, centrationcentration idealideal



 Manual Manual capsulotomycapsulotomy less predictable, less predictable,

less precise less precise less precise less precise



 CapsulotomyCapsulotomy diameter variabilitydiameter variability

laser = 29um manual =339um laser = 29um manual =339um

 Better IOL Better IOL centrationcentration/ position/ position/ p/ p

Dr. Brian D. Ranelle Dr. Brian D. Ranelle Texas Eye & Laser Center Texas Eye & Laser Center

(19)

Capsulotomy

(20)

Laser Assisted Cataract Surgery Laser Assisted Cataract Surgery Laser Assisted Cataract Surgery Laser Assisted Cataract Surgery

Present visual outcomes for Lasik vs. Present visual outcomes for Lasik vs.

cataract surgery

cataract surgeryg yg y

Cataract

Cataract--4040--50% 20/40 or better UCVA50% 20/40 or better UCVA

Lasik

Lasik 95% 20/20 or better UCVA95% 20/20 or better UCVA

Lasik

Lasik-- 95% 20/20 or better UCVA95% 20/20 or better UCVA

Introduction of

Introduction of FemtosecondFemtosecond technology technology

b i t t t i l

brings cataract surgery to a visual brings cataract surgery to a visual

level comparable with Lasik except for level comparable with Lasik except for

biditi biditi commorbidities commorbidities

(21)

Laser Assisted Cataract

Surgery

LenSx

Capsulotomy

(22)

Laser Assisted Cataract

Surgery

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

(23)

(24)

Laser

Laser Microincisional

Microincisional

Cataract Surgery

Allows small incisions of

any size

Precise corneal incisions Incisions can be placed anywhere on cornea

anywhere on cornea

Can still make manual incisions

(25)

Laser

Laser Arcuate

Arcuate Incisions

Incisions

for Astigmatism



 73% of population has > .50 D of 73% of population has > .50 D of

astigmatism

astigmatismgg



 39% has > 1.00D of astigmatism39% has > 1.00D of astigmatism



 Treat more ATR astigmatism lessTreat more ATR astigmatism less



 Treat more ATR astigmatism, less Treat more ATR astigmatism, less

WTR astigmatism WTR astigmatism

A id fli i i



 Avoid flipping axisAvoid flipping axis



 Combine Combine arcuatesarcuates with with ToricToric IOL’sIOL’s

(26)

Refractive Accuracy:

yy

Addressing Astigmatism

Manual

TORIC IOL TORIC IOL

Manual

LRI

O C O

(27)

Laser

Laser Arcuate

Arcuate Nomogram

Nomogram

Laser

Laser Arcuate

Arcuate Nomogram

Nomogram

LRI’s LRI’s LenSx LRI s LRI s .50D 1 = 45* .50D 1 = 45* 75D 2 30* 75D 2 30* .50D 1 = 30* .50D 1 = 30* .75D 2 = 20* .75D 2 = 20* .75D 2 = 30* .75D 2 = 30* 1.50D 2 = 60* 1.50D 2 = 60* .75D 2 20 .75D 2 20 1.50 D 2 = 40* 1.50 D 2 = 40* 3 00D 2 60* 3 00D 2 60* 3.00D 2 = 90* 3.00D 2 = 90* 3.00D 2 = 60* 3.00D 2 = 60* Donnenfeld nomogram

30% Reduction from LRI nomogram

Residual Astigmatism is the most common cause of reduced vision after cataract surgery

(28)

Laser Assisted Cataract:

Corneal Incisions



 Primary and secondary incisions more Primary and secondary incisions more

reproducable

reproducablepp



 ArcuateArcuate incisions preciseincisions precise



 ArcuatesArcuates 8080 85% deep85% deep



 ArcuatesArcuates 8080--85% deep85% deep



 ArcuatesArcuates at 8.5at 8.5--9mm OZ9mm OZ



 Open Open arcuatesarcuates at surgery or laterat surgery or later



 Improved visual outcomesImproved visual outcomespp

(29)

Laser Assisted Cataract

Surgery: Addressing

Astigmatism

g

Arcuate Incisions LenSx Dr. Brian D. Ranelle Dr. Brian D. Ranelle Texas Eye & Laser Center Texas Eye & Laser Center

(30)

Laser Assisted

Fragmentation of Lens



 Breaks up, chops nucleusBreaks up, chops nucleus



 Easier to removeEasier to remove



 Easier to removeEasier to remove



 Less surgical timeLess surgical time

S l t

S l t l fl f titi titi



 Select Select nucleofractiousnucleofractious options:options:

Quadrant Quadrant Cylinder Cylinder Combination Combination Combination Combination

(31)

Laser Assisted Cataract

Surgery

Laser Lens Chop

Dr. Brian D. Ranelle Dr. Brian D. Ranelle Texas Eye & Laser Center Texas Eye & Laser Center

(32)

Lens Fragmentation

(33)

Advantages of Laser Assisted Advantages of Laser Assisted gg

Cataract Surgery Cataract Surgery



 Excellent control of laser treatmentExcellent control of laser treatment



 Ability to produce precise andAbility to produce precise and



 Ability to produce precise and Ability to produce precise and

reproducible incisions reproducible incisions



 Accurate placement of IOL postAccurate placement of IOL post op orop or



 Accurate placement of IOL postAccurate placement of IOL post--op or op or

Effective Lens Position (ELP) Effective Lens Position (ELP)

C t A ti ti



 Corrects AstigmatismCorrects Astigmatism



 Less refractive and surgical surprises Less refractive and surgical surprises

(34)

Laser Assisted Cataract

Surgery: Effective Lens

Position (ELP)

(

)



 Precise Precise capsulotomycapsulotomy (5mm) , no (5mm) , no

collateral tissue damage collateral tissue damage collateral tissue damage collateral tissue damage



 Ideal IOL placement in capsular bagIdeal IOL placement in capsular bag



 Stronger Stronger capsulotomycapsulotomy, less tears, less tears



 Goal is Better visual outcomesGoal is Better visual outcomes



 Especially important with Premium Especially important with Premium

IOL’s IOL’s IOL s IOL s

(35)

Laser Assisted Cataract

Surgery: Ultrasound Power

Reduced Ultrasound Power/Time Reduced Ultrasound Power/Time

 42% reduction in42% reduction in PhacoPhaco PowerPower

 42% reduction in 42% reduction in PhacoPhaco. Power. Power

 50% reduction in 50% reduction in PhacoPhaco. time. time

P ti f d th li l ll

 Preservation of endothelial cellsPreservation of endothelial cells

 Less corneal edema/ corneal thicknessLess corneal edema/ corneal thickness

(36)

Laser Assisted Cataract

Surgery

Advantages Advantages LenSx LenSx LenSx LenSx

(37)

Laser Assisted Cataract

Surgery: Advantages



 Uniform size, centered Uniform size, centered capsulotomycapsulotomy



 ReproduceableReproduceable corneal incisionspp corneal incisions



 ArcuateArcuate incisions for astigmatismincisions for astigmatism

 Nucleus removal: LessNucleus removal: Less phacophaco power/power/

 Nucleus removal: Less Nucleus removal: Less phacophaco. power/ . power/

time time

Less post

Less post op inflammation with betterop inflammation with better



 Less postLess post--op inflammation, with better op inflammation, with better

vision faster vision faster

d bl ( )



 IOL position more predictable (ELP)IOL position more predictable (ELP)

(38)

Three Big Advantages of

g

Laser Cataract Surgery

44% Reduction in Phaco. Power 50% Reduction in Phaco. Time Reduced endotheliai cell loss

(39)

Standared

Phacoemulsification

M t th d f t t M t th d f t t 

 Most common method of cataract Most common method of cataract

surgery surgery



 More ultrasound needed as cataract More ultrasound needed as cataract

becomes more dense becomes more dense



 Excess ultrasound energy problems:Excess ultrasound energy problems:

corneal edema/ endothelial cell loss corneal edema/ endothelial cell loss corneal edema/ endothelial cell loss corneal edema/ endothelial cell loss wound burns

wound burns

ti ith t ti l li ti

more time with potential complications more time with potential complications

(40)

Standard

Phacoemulsification

Over 50% increase in increase in ultrasound power Extends phaco. time Increased co neal edema corneal edema More post-op inflamation

(41)

Methods To Reduce

Ultrasound Power



 Ultrasound modulation of energyUltrasound modulation of energy

Torsional

Torsional phacophaco

Torsional

Torsional phacophaco

Pulse duty cycle Pulse duty cycle

S i l T h i t d

 Surgical Techniques to reduce Surgical Techniques to reduce

power/

power/phacophaco. time. time

Chopping techniques of lens Chopping techniques of lens Viscoelastics

Viscoelastics

(42)

Disadvantages of Laser Assisted Disadvantages of Laser Assisted gg

Cataract Surgery Cataract Surgery



 Post Post ––op op subconjunctivalsubconjunctival hemorrhageshemorrhages--mildmild 

 Cost of equipment highCost of equipment highq pq p gg 

 Adds time to routine cataract surgeryAdds time to routine cataract surgery 

 Not reimbursed by Not reimbursed by medicareot e bu sed byot e bu sed by ed ca emedicare/ insuranceed ca e/ su a ce/ insurance/ su a ce 

 Not all patients Not all patients candiatescandiates-- tight lids, small tight lids, small

pupils, glaucoma, corneal conditions, ARMD pupils, glaucoma, corneal conditions, ARMD

p p , g , ,



 Not all patients can be dockedNot all patients can be docked

(43)

Laser Assisted Cataract Surgery: Laser Assisted Cataract Surgery: g yg y

Other Uses of Laser Other Uses of Laser



 Corneal surgeriesCorneal surgeries-- Transplants, Transplants,

Lamellar

Lamellar SxSx



 Refractive laser/ Refractive laser/ IntrastromalIntrastromal vision vision

correction correction correction correction



 Collagen crossCollagen cross--linking for KC / linking for KC / ectasiaectasia

S l l

S l l GlGl SS



 ScleralScleral surgerysurgery-- Glaucoma SurgeryGlaucoma Surgery



 Corneal wedge resections etcCorneal wedge resections etc

(44)

Laser Assisted Cataract Surgery: Laser Assisted Cataract Surgery: g yg y

Goals Goals



 Increased precision / safetyIncreased precision / safety



 Makes cataract surgery moreMakes cataract surgery more



 Makes cataract surgery more Makes cataract surgery more

reproducible reproducible



 Surgeon directed computer controlledSurgeon directed computer controlled



 Surgeon directed, computer controlledSurgeon directed, computer controlled



 Achieve true refractive outcomes Achieve true refractive outcomes

bl t L ik bl t L ik comparable to Lasik comparable to Lasik



 Will it become the Standard of Care?Will it become the Standard of Care?

(45)

Laser Vision Correction:

Femtosecond

Femtosecond Lasers

Lasers



 Laser corneal surgeryLaser corneal surgery

Lasik corneal flaps Lasik corneal flapspp Lameller

Lameller SxSx, Wedge resections, Wedge resections



 Laser assisted cataract surgeryLaser assisted cataract surgeryase ass sted cata act su ge yase ass sted cata act su ge y

Clear lens removal/Refractive lens exchange Clear lens removal/Refractive lens exchange Clear lens removal/Refractive lens exchange Clear lens removal/Refractive lens exchange Combined with

Combined with PresbyopicPresbyopic/ / ToricToric IOL’sIOL’s

(46)

Beginning Lessons



 Good Docking is the KeyGood Docking is the Key

Good lid speculum Good lid speculum Proparacaine

Proparacaine applied to PIapplied to PI Proper head position

Proper head position P e ent P oblems P e ent P oblems



 Prevent ProblemsPrevent Problems

Meniscus creep Meniscus creep

Air bubbles with dock Air bubbles with dock Air bubbles with dock Air bubbles with dock Conjunctival

Conjunctival obstructionobstruction Lid hitting speculum

Lid hitting speculumg pg p

(47)

Beginning

Beginning Lessions

Lessions

Beginning

Beginning Lessions

Lessions



 Learning curve Learning curve 

 ReRe--Dock several times for good suctionDock several times for good suction 

 Adjust surgical scheduleAdjust surgical schedule 

 Laser setLaser set--up: Outside OR idealup: Outside OR ideal

A oid complications A oid complications



 Avoid complicationsAvoid complications

Ant./Post. Capsule tears Ant./Post. Capsule tears Capsule block

Capsule block--gentlegentle hydrodissectionhydrodissection Capsule block

Capsule block gentle gentle hydrodissectionhydrodissection



 If docking not good or If docking not good or capsulotomycapsulotomy poor convert to poor convert to

routine case! routine case!

(48)

Integration of the Laser

g

in the ASC



 Space: In ASC between OR’sSpace: In ASC between OR’s



 Time: Adds 5 minutes/ caseTime: Adds 5 minutes/ case



 Time: Adds 5 minutes/ caseTime: Adds 5 minutes/ case



 Access: Make it easy for patients/ staffAccess: Make it easy for patients/ staff

M C t / M k ti



 Money: Costs/ MarketingMoney: Costs/ Marketing



 People: PatientsPeople: Patients/ Staff / Staff

(49)

Personal Experience with

p

LACS



 Anterior capsule tears Anterior capsule tears



 Posterior capsule tearsPosterior capsule tears



 Posterior capsule tears Posterior capsule tears



 Reduced Reduced phacophaco. time. time

L t

L t i fli fl titi



 Less postLess post--op inflammationop inflammation



 Faster visual recoveryFaster visual recovery



 Excellent IOL positionExcellent IOL position



 Safer than manual techniqueSafer than manual technique



 Safer than manual techniqueSafer than manual technique

(50)

Laser assisted cataract surgery raises Laser assisted cataract surgery raises the bar in vision correction to a new the bar in vision correction to a new t e ba s o co ect o to a e t e ba s o co ect o to a e level. It is customizable, it is more level. It is customizable, it is more precise and more

precise and more reproduceablereproduceable than than standard cataract surgery. This will standard cataract surgery. This will benefit the patient with better visual benefit the patient with better visual outcomes and safety Our patients

outcomes and safety Our patients outcomes and safety. Our patients outcomes and safety. Our patients should see the results with this

should see the results with this advanced technology.

advanced technology.

advanced technology. advanced technology.

(51)

Optiwave

Optiwave Refractive

p

Refractive

Analysis (ORA) (Orange)



 Customizes cataract surgery with Customizes cataract surgery with

LenSx

LenSx: : LenSxLenSx PlusPlus



 Enhanced Enhanced wavefrontwavefront image usedimage used



 Improves accuracy of IOL selectionImproves accuracy of IOL selection



 Improves accuracy of IOL selectionImproves accuracy of IOL selection



 IntraoperativeIntraoperative astigmatic correction: astigmatic correction:

Both LRI’s and

Both LRI’s and ToricToric IOL’sIOL’s

Both LRI s and

Both LRI s and ToricToric IOL sIOL s



 Refines refractive results for better Refines refractive results for better

i l t

visual outcomes visual outcomes

(52)

Blade

Blade--Free Laser Assisted

Free Laser Assisted

Cataract Surgery



 Technology has given Technology has given

surgeons choices surgeons choices



 Surgeons need to Surgeons need to

give patients choices give patients choices



 Ideal for Premium Ideal for Premium

IOL’s IOL’s



 Achieving greater Achieving greater

value in value in Refractive/Cataract Refractive/Cataract Dr. Brian D. Ranelle Dr. Brian D. Ranelle Texas Eye & Laser Center Texas Eye & Laser Center

Refractive/Cataract Refractive/Cataract Surgery

(53)

The New Frontier: Laser

i

d

i

d

Assisted Cataract Surgery

Weapon Grade Weapon Grade Vision“Baby Vision“Baby”” Dr. Brian D. Ranelle Dr. Brian D. Ranelle Texas Eye & Laser Center Texas Eye & Laser Center