1. Alan Solinsky, MD
David Jeng, MD
1013 Farmington Ave
West Hartford, CT 06107
(860) 233-2020
david.jeng@solinskyeyecare.com

2. This course provides an overview of how
femtosecond lasers can and will benefit
patients with cataracts and astigmatism.

3.  To understand the uses of the femtosecond
laser
 To review the features of various systems and
specifically the Alcon LenSx® Laser
 To review the evidence in support of the
functionality of femtosecond lasers
 To recognize the benefit of the femtosecond
laser in cataract surgery

4.  Neither Alan Solinsky nor David Jeng has direct
financial or proprietary interest in any of the
companies or services mentioned in this
presentation
 Neither Alan Solinsky nor David Jeng has received
commercial support from any of the mentioned
companies
 Alan Solinsky is affiliated with Allergan as a
speaker.
 The content and format of this course may reflect
commercial bias BUT it does not claim superiority
of any commercial product or service

5.  Earlier diagnosis and treatment before
substantial vision loss
 Baby Boomer patients demanding high quality
post-operative vision
 New surgical approaches and lens implants
available to improve UCVA for many patients

8.  A laser that emits optical pulses with a
duration in the range of femtoseconds (1 fs =
10-15 seconds)
 Allows for precise cutting of tissue with
minimal collateral damage
 Utilized since 2001 in ophthalmologic
procedures such as LASIK, corneal transplants

9.  Alcon LenSx® (approved for all steps)
 LensAR® system (approved for all steps)
 OptiMedica Catalys® (approved for all steps)
 B+L Victus® (approved for corneal flaps,
incisions and anterior capsulotomy)
 AMO Intralase® FS (used in LASIK flaps,
approved for arcuate incisions only)

12.  Liquid Optics™ Interface
 Integral Guidance™
 Attached ergonomic surgical chair

14.  Augmented Reality™
 Optical ray-tracing (Schleimpflug imaging)
 Lens Tilt detection
 Small footprint and Articulating arm may
allow for positioning in one operating room

16.  Allows for LASIK flap creation and corneal
incisions

18.  The LenSx® Laser was the first femtosecond laser
cleared by the FDA for use in cataract surgery. It is
indicated for:
 Anterior capsulotomy
 Lens fragmentation
 All corneal incisions
 The LenSx® Laser brings a new level of precision to
these surgical steps through a number of high-tech
features:
 Real-time video imaging with integrated OCT.
Provides three-dimensional visualization of the entire
anterior segment during docking, planning and
procedure.
 Curved patient interface. Designed for patient
comfort, ease of use and optimal laser performance.
 Intuitive touch screen graphic user interface. Allows
each step of the procedure to be easily planned,
customized and executed.
 True image-guided surgical planning. Enables the
surgeon to precisely program the size, shape and
location of each incision.

19.  Currently, FDA-approved for 3 steps:
 All corneal incisions
 Anterior capsulotomy
 Lens fragmentation
 But, why is this important?

20.  Corneal Incisions
 Anterior capsulotomy
 Lens fragmentation

23.  Offers a new level of precision and
reproducibility in ophthalmic surgery
 Helps to optimize the capsular and corneal
incisions
1. Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at: Annual
Meeting of the American Academy of Ophthalmology; October 24-27, 2009;
2. Nagy, ZZ. Intraocular femtosecond laser applications in cataract surgery. Cataract & Refractive Surgery Today. September 2009:79-
82. San Francisco, CA.

25.  LenSx® features an onboard, proprietary optical
coherence tomographer (OCT) in conjunction with
a video microscope, to provide three-dimensional
visualization of the anterior segment. It can
visualize multiple views, including:
 Side View, Capsular Bag
 Topographic View, Lens
 Side View, Cornea

26.  Catalys also includes integrated OCT
 LensAR uses ray-tracing technology for 3D
visualization

27.  A disposable, single-use, soft contact lens is used to dock with the
patient's eye.
 This curved patient interface is designed for patient comfort, ease
of use, and optimal laser performance.
 Surgeons guide and gently dock the disposable patient interface
using the video microscope and integrated real-time OCT.
 The unique shape of the patient interface helps maintain a more
natural curvature of the patient's cornea. This helps to improve
surgical accuracy during the LenSx® Laser procedure.

28.  Both Catalys and LensAR have a low-pressure
fluid-filled docking system

29.  Corneal Incisions
 Anterior capsulotomy
 Lens fragmentation

30.  Corneal Incisions
 Primary and Secondary Incisions
 Astigmatism
 Anterior capsulotomy
 Lens fragmentation

31.  Imprecise tunnel length and geometry
 Frequently require stromal hydration to seal
wound, which induces corneal edema
 Poor wound construction may lead to snowball
effect of intraoperative difficulties (anterior
chamber maintenance and fluid dynamics)
 Incisions may be unstable, which may lead to
increased risk of infection
Behrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds after
phacoemulsification surgery
using optical coherence tomography in the early postoperative period. J Refract Surg, 2008;24(1):46-9
Taban M, Behrens A. Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of
literature. Arch
Ophthalmol. 2005;123(5):613-20

33.  Primary and secondary incisions (including
arcuate incisions) can be created
 Size and degree of each incision and its
orientation are customizable
Single-plane cut
Two-plane cut
Three-plane cut

35.  Corneal Incisions
 Primary and Secondary Incisions
 Astigmatism
 Anterior capsulotomy
 Lens fragmentation

37.  Manually created using
handheld diamond
blade
 Inconsistent depth
control
 Risk of perforating
cornea
 Unpredictable effect
due to imprecise wound
architecture and depth
 No image-guided
planning or
visualization

38.  Image-guided surgical
planning with OCT
 Real time corneal thickness
 Computer-customized
incisions
 % depth
 Incision length and position
 3D visualization of incision
placement
 Predictable incision width
 Titratable incisions
(adjustable intraoperatively
and post-operatively in
office)

40.  Corneal Incisions
 Anterior capsulotomy
 Lens fragmentation

41.  Continuous and perfectly curvilinear
 Potentially stronger with lower likelihood of
anterior capsular tears

42.  Only 10% of manually created capsulorhexis
achieved a similar diameter accuracy of +/-0.25
mm vs. nearly 100% of LenSx procedures
Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at:
Annual
Meeting of the American Academy of Ophthalmology; October 24-27, 2009; San Francisco, CA.
Nagy, ZZ. Intraocular femtosecond laser applications in cataract surgery. Cataract & Refractive Surgery Today. September
2009:79-82.

43. Anterior Capsulotomy

45. “The key to highly accurate IOL power
calculation is being able to correctly predict
ELP for any given patient and IOL”
Studies show that the size of capsulorhexis affects
ELP
Capsulorhexis needs to be round, centered, and
just smaller than the IOL optic diameter
Haigis W, Lege B, Miller N, Schneider B. Comparison of immersion ultrasound biometry and partial coherence
interferometry for IOL
calculation according to Haigis. Graefes Arch Clin Exp Ophthalmol, 2000;238:765-73
Cekic O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg
Lasers,
1999;30(3):185-90
Hill WE. Hitting Emmetropia. Chang D. (ed) In: Mastering Refractive IOLs – The Art and Science. Slack, Incorporated,
2008
Hill WE. Does the Capsulorhexis Affect Refractive Outcomes? Chang D. (ed) In: Cataract Surgery Today, Bryn Mawr
Communications,
Wayne, Pennsylvania 2009, p.78

46.  Using the available laser systems, it is possible
to precisely center the capsulorhexis and
determine the diameter and depth of the
anterior capsulotomy.

47. Manual
Femtosecond Laser

48.  Non-randomized, prospective, single site, single
surgeon study
 With single lens type, ALCON monofocal SN60WF
 Manual group (n=26)
 Attempted 5.0mm manual capsulotomy
 LenSx Laser group (n=22)
 Femtosecond laser created 5.0mm capsulotomy
 Accuracy to Target, Actual ELP
 No significant difference in baseline between
cohortsRobert J Cionni MD. Presented AAO 2011 Refractive Sub-Specialty Day, “Comparison of Effective Lens Position and Refractive
Outcome:
Femtosecond Laser vs Manual Capsulotomy”

51.  Corneal Incisions
 Anterior capsulotomy
 Lens fragmentation

52.  The femtosecond laser performs lens
fragmentation, creating easily dissected
segments for efficient removal with reduced
phaco power.
 Most systems allow the surgeon to set the lens
fragmentation pattern, from pie cuts to
complete liquefaction.

53.  Patterns can be customized for the cataract
type
 Spares ultrasonic power and time

54. Ecsedy M, Miháltz K, Kovács I, Takács A, Filkorn T, Nagy ZZ, Effect of Femtosecond
Laser Cataract
Surgery on the Macula, Journal of Refractive Surgery, 2011;27:717-722.
Miháltz K, Knorz MC, Alio JL, Takács A, Kránitz K, Kovács I, Nagy ZZ, Internal
Aberrations and
Optical Quality After Femtosecond Laser Anterior Capsulotomy in Cataract
Surgery, Journal of Refractive Surgery, 2011;27:711-716.
Nagy ZZ, Kránitz K, Takács A, Miháltz K, Kovács I, Knorz MC, Comparison of
Intraocular Lens
Decentration Parameters After Femtosecond and Manual Capsulotomies, Journal
of Refractive Surgery, 2011;27:565-569.
Kránitz K, Takács A, Miháltz K, Kovács I, Knorz MC, Nagy ZZ, Femtosecond Laser
Capsulotomy and
Manual Continuous Curvilinear Capsulorrhexis Parameters and Their Effects on
Intraocular Lens Centration, Journal of Refractive Surgery, 2011;27:559-563.
Nagy ZZ, Takács A, Filkorn T, Sarayba M, Initial Clinical Evaluation of an Intraocular
Femtosecond
Laser in Cataract Surgery, Journal of Refractive Surgery, 2009;25:1053-1060

55.  Image-guided femtosecond laser designed
specifically for refractive cataract surgery
 Using a customizable 3-D surgical platform, it
allows visualization, customization and
completion of many of the most challenging
steps of cataract surgery:
 Anterior capsulotomy
 Lens fragmentation
 All corneal incisions