Excelling at femtosecond laser cataract surgery is a fast learning curve with the current intuitive system; however, to raise the performance with the technology, surgeons can customize their laser settings. The laser is a tool that is meant to make surgeons become more efficient and precise, but it can also create a less stressful surgery and make tough cases more routine. From many years of laser cataract surgery experience, I have learned how to customize the settings on my femtosecond laser system to achieve optimal outcomes for my patients. The more often that I use the laser for cataract surgery, the more I recognize its value both when in the operating room and for the entire patient cataract experience.
Certainly, out of the box, laser cataract surgery with the Catalys femtosecond laser platform (Johnson & Johnson Vision) is ready to go: The settings are dialed in and are outstanding; the surgeon need not change a thing. The system has been engineered using rigorous bench testing to establish its standard settings. However, I have found there can be advantages to further optimizing some of the device's parameters. And by customizing laser settings, surgeons then have their own templates, similar to the phacoemulsification machine programs they rely on.
A complete centered capsulotomy that is significantly faster than a manual capsulorrhexis is a powerful step in refractive cataract surgery. Using the Catalys’ default standard setting, the capsulotomy takes about 1.6 seconds to complete. By easily changing a couple of parameters, the surgeon can decrease the length of time it takes to create the capsulotomy to 1 second. It can be made even faster, without compromising precision, allowing even less chance for patient movement. A sub-1-second capsulotomy can also add value in patients with white intumescent cataracts, where surgeons worry about elevated intralenticular pressures. This customization further enhances the procedure's safety and repeatability in my hands.
I see the benefits of a fast — and complete — capsulotomy in every case. To describe this advantage to patients, video and print are used for preoperative consults, and the memorable piece of the visit is, with a 23-inch touchscreen monitor, use of a drawing tool to show patients the lens anatomy, surgery types and IOL options. Also highlighted is that a manual capsulotomy takes approximately 20 seconds with a needle, whereas a laser capsulotomy takes 1 second. That hits home. Patients also connect with the concept that there is reduced stress on the eye by using less phacoemulsification energy and shorter time needed to break up the cataract that has been segmented or pre-softened by the laser.
For the challenge of smaller pupils, surgeons usually have a minimum acceptable capsulotomy size they are comfortable working with; without a laser, this diameter is just a visual estimate and depends on the shape of the pupil. With a laser, the diameter is measured exactly, and surgeons can choose their cut-off for minimum capsulotomy diameter; some may want at least 4.2 mm, for others that may be 4.5 mm.
Most dilated pupils are over 5 mm, and the real-time edits on the Catalys laser screen allow the surgeon to expand the pupil overlay, which increases the treatment diameter. To accomplish this, one assesses the pupil size based on the system's OCT measurements and adjusts the laser’s safety margin, allowing creation of a capsulotomy closer to the iris than the default settings would allow. For example, if the OCT-measured pupil size is 5 mm, the software plans a capsulotomy of 4 mm, because the untreated margin is set at 1 mm. With the Catalys, the surgeon has the freedom to manually adjust the pupil size to make a larger capsulotomy safely by decreasing that margin.
Once surgeons become comfortable with the platform, they will discover that bypassing some of the defaults and adjusting settings based on their experience will further enhance their comfort and speed with the procedure.
Anterior segment data obtained with the Catalys high-resolution OCT images shows the anatomy with impressive clarity. Many surgeons will use a quadrant or sextant fragmentation pattern on nearly all cases, and then add in softening on more dense cataracts. Others may always soften the lens; this of course is dependent on one’s phacoemulsification technique. The beauty is that the lens treatment time is fast, creates less gas formation than one would think, and the OCT imaging gives you nearly full lens anatomy, which our office machines just cannot image.
Looking at anterior chamber depth, lens thickness and capsule anatomy shows whether any real-time edits need to be made, such as suppressing fragmentation if there is a defect or irregularity seen on the posterior capsule. The imaging also helps to know what to expect in the OR, so there are fewer surprises. Especially in tough cases, it is comforting to know that the capsulotomy is automated and the lens is pre-treated.
Customized laser cataract surgery is here to stay, and surgeons can gain experience quickly with the Catalys, taking advantage of its customizability and relying on its precision and predictability; the more one uses it, the easier it is to appreciate its benefits in virtually every case.
Disclosure: Younger reports he is a consultant to Johnson & Johnson Vision.