1.Alan Solinsky, MDDavid Jeng, MD

2. Overview The Anatomy The Symptoms The Surgery The Future 3. Anatomy 4. Risks Advanced age; A family history of cataracts; Extensive exposure to sunlight or UV light; Smoking; Diabetes, Obesity, High blood pressure; Long-term use of steroid medication (especiallycombined use of oral and inhaled steroids) Previous eye injury or inflammation in the eye; Previous eye surgery 5. Symptoms Painless cloudy, blurry or dim vision More difficulty seeing at night or in low light Sensitivity to light and glare Seeing halos around lights Faded or yellowed colors The need for brighter light for reading and otheractivities Frequent changes in eyeglass or contact lensprescription Double vision within one eye 6. Remember Just because you have a cataract, does NOT mean youneed surgery Must weigh the risks and benefits of surgery for eachindividual 7. Recommendations Have an eye exam every year if youre older than 65, or every twoyears if younger. Protect your eyes from UV light by wearing sunglasses that blockat least 99 percent UV and a hat. If you smoke, quit. Smoking is a key risk factor for cataracts. Use brighter lights for reading and other activities; a magnifyingglass may be useful, too. Limit driving at night once night vision, halos or glare becomeproblems. Take care of any other health problems, especially diabetes. Get the right corrective lenses (glasses/contacts) to correct yourvision; when it becomes too difficult to complete your regularactivities, consider cataract surgery. 8. Cataract 9. Cataract Surgery 10. Corneal Incision 11. Capsular Opening 12. Removal of Cataract 13. Insertion of Intraocular Lens 14. Position of Intraocular Lens 15. Goals To remove the cataract To improve vision by implanting the correctintraocular lens But, the standard lens would still require readingglasses However, there are options to minimize dependenceon glasses 16. Premium Intraocular Lenses 17. Risks There are inherent risks in everything we do, especiallyin medicine Cataract surgery is one of the safest surgeries available Technique has evolved and has been refined tominimize risk 18. Common Question Is this laser surgery? No, this is not laser surgery But. 19. The Future Is Now Bladeless, laser-assisted cataract surgery LenSx Laser System Same laser used for LASIK 20. Need for Improved Outcomes 21. What is a femtosecond laser? A laser that emits optical pulses with a duration in therange of femtoseconds (1 fs = 10-15 seconds) Allows for precise cutting of tissue with minimalcollateral damage Utilized since 2001 in ophthalmologic procedures suchas LASIK, corneal transplants 22. Commercially Available Systems 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 andanterior capsulotomy) AMO Intralase FS (used in LASIK flaps, approvedfor arcuate incisions only) 23. Alcon LenSx 24. LenSx first femtosecond laser cleared by the FDA for use incataract surgery. It is indicated for: All corneal incisions Anterior capsulotomy Lens fragmentation The LenSx Laser brings a new level of precision to thesesurgical steps through a number of high-tech features: Real-time video imaging with integrated OCT. Providesthree-dimensional visualization of the entire anteriorsegment during docking, planning and procedure. Curved patient interface. Designed for patientcomfort, ease of use and optimal laser performance. 25. How is a femtosecond laser used toassist in cataract surgery? Currently, FDA-approved for 3 steps: All corneal incisions Anterior capsulotomy Lens fragmentation But, why is this important? 26. Limitations of Traditional CataractSurgery 27. Femtosecond Laser Offers a new level of precision and reproducibility inophthalmic surgery Helps to optimize the capsular and corneal incisions1. Nagy, ZZ. 1-year clinical experience with a new femtosecond laser for refractive cataract surgery. Paper presented at: Annual Meeting ofthe 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. 28. Real-Time Images 29. SoftFit Patient Interface A disposable, single-use, soft contact lens is used to dockwith the patients eye. This curved patient interface is designed for patientcomfort, ease of use, and optimal laser performance. Surgeons guide and gently dock the disposable patientinterface using the video microscope and integrated real-time OCT. The unique shape of the patient interface helps maintain amore natural curvature of the patients cornea. This helpsto improve surgical accuracy during the LenSx Laserprocedure. 30. Manual Clear Corneal Incisions Imprecise tunnel length and geometry Frequently require stromal hydration to sealwound, which induces corneal edema Poor wound construction may lead to snowball effectof intraoperative difficulties (anterior chambermaintenance and fluid dynamics) Incisions may be unstable, which may lead toincreased risk of infectionBehrens A, Stark WJ, Pratzer KA, McDonnell PJ. Dynamics of small-incision clear cornea wounds after phacoemulsificationsurgery using optical coherence tomography in the early postoperative period. J Refract Surg, 2008;24(1):46-9Taban M, Behrens A. Newcomb RL, et al. Acute endophthalmitis following cataract surgery: a systematic review of literature.Arch Ophthalmol. 2005;123(5):613-20 31. Manual Corneal Incisions 32. Laser Corneal Incisions 33. Astigmatism in Cataract Patients 34. Arcuate Incisions Manually created usinghandheld diamond blade Inconsistent depth control Risk of perforating cornea Unpredictable effect due toimprecise woundarchitecture and depth No image-guided planningor visualization 35. Laser Arcuate Incisions Image-guided surgicalplanning with OCT Real time corneal thickness Computer-customizedincisions % depth Incision length and position 3D visualization of incisionplacement Predictable incision width Titratable incisions(adjustable intraoperativelyand post-operatively inoffice) 36. Laser Arcuate Incisions 37. Anterior Capsulotomy Continuous and perfectly curvilinear Potentially stronger with lower likelihood of anteriorcapsular tears 38. Anterior CapsulotomiesManualFemtosecond Laser 39. Why does this matter?Anterior Capsulotomy 40. Effective Lens Position 41. Effective Lens PositionThe key to highly accurate IOL power calculation isbeing able to correctly predict ELP for any givenpatient and IOLStudies show that the size of capsulorhexis affects ELPCapsulorhexis needs to be round, centered, and justsmaller than the IOL optic diameterHaigis W, Lege B, Miller N, Schneider B. Comparison of immersion ultrasound biometry and partial coherence interferometryfor IOLcalculation according to Haigis. Graefes Arch Clin Exp Ophthalmol, 2000;238:765-73Cekic O, Batman C, The relationship between capsulorhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers,1999;30(3):185-90Hill WE. Hitting Emmetropia. Chang D. (ed) In: Mastering Refractive IOLs The Art and Science. Slack, Incorporated, 2008Hill WE. Does the Capsulorhexis Affect Refractive Outcomes? Chang D. (ed) In: Cataract Surgery Today, Bryn MawrCommunications,Wayne, Pennsylvania 2009, p.78 42. Capsulotomy Using the available laser systems, it is possible toprecisely center the capsulorhexis and determine thediameter and depth of the anterior capsulotomy. 43. Lens Fragmentation The femtosecond laser performs lensfragmentation, creating easily dissected segments forefficient removal with reduced phaco power. Most systems allow the surgeon to set the lensfragmentation pattern, from pie cuts to completeliquefaction. 44. Lens Fragmentation Patterns can be customized for the cataract type Spares ultrasonic power and time 45. LenSx Laser System Image-guided femtosecond laser designed specificallyfor refractive cataract surgery Using a customizable 3-D surgical platform, it allowsvisualization, customization and completion of manyof the most challenging steps of cataract surgery: Anterior capsulotomy Lens fragmentation All corneal incisions 46. Laser-Assisted Cataract SurgeryMore reproducible incisions+ More precise positioning of capsulotomy+ Less ultrasound energy needed___________________________________= More predictable outcomes