August 01, 2019
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Laser plus phaco for dense cataracts enhances safety, visual outcomes

Using the laser to presoften tough nuclei reduces trauma and saves zonules.

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Removing extremely dense cataracts can often be traumatic to the corneal endothelium due to the increased amount of phacoemulsification energy required to break up tough nuclei. The resulting edema can have a significant impact on corneal health, lasting from days to weeks after surgery. If these patients have underlying endothelial disease such as Fuchs’ dystrophy with an already borderline endothelium, cataract removal can cause full corneal decompensation. It has been well accepted that laser nuclear fragmentation significantly decreases the amount of phacoemulsification energy needed in the eye.

Laser for safety, precision

Marjan Farid
Marjan Farid

Using femtosecond laser technology in cases of hard cataract and/or a compromised cornea can enhance safety and ease removal by presoftening the nucleus. With the Catalys laser (Johnson & Johnson Vision), for example, surgeons can adjust the detail settings, enabling the desired fragmentation patterns. I modify the settings to utilize higher energy, and then I select a closely grouped spot size and separation for the system’s photodisrupting cavitation bubbles to achieve an intense breakup of the nucleus. The Catalys interface is user friendly, making it simple to go into the detail settings to select the specifications required based on the patient’s cataract.

I let patients know they will be under the laser a little longer because of their dense cataract. Laser time increases from about 30 or 40 seconds to 2 to 3 minutes; however, because of the curved and water-filled interface, the procedure is comfortable and easily tolerated. Even in a dense, dark-brown leathery cataract, these settings significantly improve the central nuclear breakup. The chance of rupturing the posterior capsule is greatly minimized, as the laser treatment helps a hard lens behave more like a moderate cataract, breaking up beautifully with minimal strain and trauma to the capsular bag and zonules.

It is important to note that I still take the precaution of using a dispersive viscoelastic to protect the corneal endothelium. I may even still pause in the middle of my nuclear removal to place Healon EndoCoat (sodium hyaluronate, Johnson & Johnson Vision), but now my risk for increased manipulation and associated complication is less. For my setting in dense cataracts, see Figure 1.

Customized settings for dense cataracts
Figure 1. Customized settings on the Catalys for dense cataracts.

Source: Marjan Farid, MD


I also use femtosecond laser lens softening for patients who have zonulopathy from previous trauma as well as in cases of pseudoexfoliation. The laser centers the capsulotomy over the entire capsular bag rather than just the pupil or the limbus. This way, even if the capsule has shifted, the capsulotomy opening is central to the bag, ensuring final lens centration. For cases of zonulopathy, it is crucial I am in the eye for the shortest amount of time possible, minimizing the lens manipulation to limit strain on the remaining zonules.

Premium implants

I have shifted my premium IOL patients to only laser-based procedures. I realized that when implanting multifocal or extended depth of focus IOL technology, I need to maximize that precision when it comes to making the capsulotomy as well. With the laser, I can ensure the advanced lens is perfectly centered to provide the best outcomes possible.


Femtosecond laser technology is a valuable tool for enhancing the safety and precision of cataract surgery in patients with compromised endothelium due to trauma or disease as well as those with hard, dense nuclei. By customizing the laser’s energy and detail settings, surgeons can achieve more efficient and less disruptive nuclear breakup as needed for difficult cases. This reduces the need for phaco energy in the eye as well as allows the surgeon to create a more precise capsulotomy for premium visual outcomes, even in patients with compromised corneal health.

Disclosure: Farid reports she is a consultant to Johnson & Johnson Vision.