2. Manual Cataract Surgery Today
2 temporal clear corneal incisions
Create a 6mm opening in the lens capsule (capsulorhexis)
that is as circular and central as possible
Fragment the clouded lens with surgical instruments and
ultrasound energy
Carefully remove all remaining lens cells with aspiration
An artificial intraocular lens (IOL) is then placed in the
capsular bag and positioned as necessary
3. CORNEAL INCISIONS
Not optimised
Variable degree of entry
Variable resulting astigmatism
Variable degree of infection risk and iris prolapse from
wound leak
5. LENS FRAGMENTATION
Variable technique
Chop
Stop and chop
Divide and conquer
Lens flip
Aim to remove the lens with the lowest possible
energy and the lowest risk to the corneal
endothelium
6. ASPIRATION
Remove as much of the remaining
lens cell population as is possible to
minimise the risk of capsule
fibrosis and posterior capsule
opacity
8. Femtosecond laser
Femtosec laser causes tissue disruption with its
near-infrared scanning pulse focused to 3um with
an accuracy of 1um
The focused laser energy generates plasma which
expands, causing a shock wave, cavitation and
bubble formation
The bubble expands and collapses causing
separation of the tissue
No heat damage due to laser properties.
9. Advantages
Precise programmable
corneal incisions
Accurate capsulorhexis
size, shape and
centration
Reduction in power
and time with unique
fragmentation patterns
Arcuate incisions
10. Manual vs. Femtocataract Surgery – 1 month
postop
Manual Surgery Femtocat Surgery
MK-00251 Rev A
11. More predictable outcomes
More predictable shape
? Better outcomes
Catalys Clinical Results:
Capsulotomy Shape
Manual Capsulorhexis
Catalys Capsulotomy
MK-00251 Rev AImages courtesy of OptiMedica Corp.
12. Catalys Clinical Results:
Capsulotomy Size
Manual (Mean SD) Catalys (Mean SD)
Deviation from
intended
diameter
339 μm 248μm 29 μm 26 μm (p<0.001)
Manual (N = 29) Catalys (N =39)
0
200
400
600
800
1000
1200
Deviationfromintendeddiameter(μm)
0
200
400
600
800
1000
1200
For comparison, the width of a human hair is approximately 85-100 microns.
MK-00251 Rev AData courtesy of OptiMedica Corp.
15. LenSx® Laser Phacofragmentation
• Cylinder pattern, utlilized for the softer lens, enables removal with
I & A only, no phaco power
• Chop pattern efficiently fragments the lens for removal with
reduced phaco power and time1
43% reduction51% reduction
1Nagy ZZ, Takacs A, Filkorn T, Sarayba M, Initial Clinical Evaluation of an Intraocular Femtosecond Laser in Cataract
Surgery, Journal of Refractive Surgery, 2009;25:1053-1060.
LSX11512SK
16
0
0.2
0.4
0.6
0.8
1
1.2
1.4
EffectivePhacoTime(min)
Comparison of Effective Phaco Time
Phaco only
Laser plus
Phaco
0
5
10
15
20
25
30
AveragePower(%)
Comparison of Average Phaco Power
Phaco only
Laser plus
Phaco
16. EffectivePhacoTime(seconds)
LOCS II
Catalys
LOCS III
Catalys
LOCS IV / IV+
Catalys
LOCS II
Standard
LOCS III
Standard
LOCS IV
Standard
LOCS II:
Standard
II: Femto III:
Standard
III: Femto IV:
Standard
IV/IV+:
Femto
EPZ
(s)
1.96 1.29 0.02 0.05 3.32 1.83 0.10 0.16 6.21 3.68 0.24 0.25
Catalys Clinical Results:
Impact on Effective Phaco Time
n= 13 n= 10 n= 18 n= 19 n= 21 n= 28
Data courtesy of Prof. Burkhard Dick, MD, PhD. Ruhr University Eye Hospital. Bochum, Germany, Member of
OptiMedica Medical Advisory Board. MK-00251 Rev A
17. Catalys treatment of LOCS grade4+ cataract
MK-00185 Rev B MK-00251 Rev A
Images courtesy of OptiMedica
18. Manual Arcuate Incisions
Manually executed by
“tracing”
corneal marks with
handheld diamond
knife
Inconsistent depth
control
Unpredictable effect as
is imprecise
19
19. Laser Arcuate Incisions
Image-guided surgical
planning with 3D
visualization:
Real time corneal thickness
Computer programmed
incisions
- % depth
- incision length and position
- 3D visualization of incision
placement
20
20. Laser Arcuate Incision
• Square edge
• Uniform depth (no ripples)
• Precise, reproducible
– Arc shape
– Arc length
– Diameter
Steinert RF, Application of the Femtosecond Laser in Cataract Surgery for the Creation of Multi-Planar, Self-Sealing
Incisions, ASCRS 2010, Boston
LSX11512SK
21
27. ENGAGE with Liquid Optics™ Interface
• Gentle dock for patient with minimal intraocular pressure (IOP) rise and
minimal hemorrhaging
• No corneal distortion or induced folds
• Clear optical path for precise imaging and laser delivery
Liquid Optics Suction
Ring
Liquid Optics Docking
Liquid Optics Advantage: Optical and comfort gains
Catalys OCT with Liquid
Optics
MK-00185 Rev B MK-00251 Rev A
28. VISUALIZE and CUSTOMIZE with
Integral Guidance™
• Integrated near-infrared video and 3D spectral domain OCT systems
visualize from anterior cornea through posterior lens
• Sophisticated algorithms customize treatment plan in 3D to anatomy of
each patient
Catalys 3D spectral domain OCT
MK-00185 Rev B
Ocular surfaces mapped and treatment
customized even when lens is tilted
MK-00251 Rev A
30. System features – comparative view
Feature Catalys
(OptiMedica)
(Designs for
Vision)
LenSx
(Alcon)
LensAR
(IQMedical)
Technolas
(B&L)
Interface Design Liquid Optics™
Interface
Curved
Applanation
Lens
Robocone™
(Immersion
Lens)
Curved
Applanation
Lens
Imaging Type 3D spectral
domain OCT
3D OCT 3D-CSI
(confocal
structured
illumination)
Online OCT
Ocular Surface
Identification
Automatic or
user-
adjustable
Manual Automatic Manual
System Origin Laser Cataract
Surgery
Femtosecond
LASIK
(Intralase)
Presbyopia
Treatment
Femtosecond
LASIK
MK-00185 Rev B
31. PART TWO: TO THE CAT CAVE!
The patient is prepared for the lens extraction as per
routine procedure.
The prepared wound is opened
Viscoelastic injected
Capsulorhexis carefully removed
Careful hydrodissection
Phacoemulsification
Aspiration and cleaning of capsule
Lens insertion
32. Patient Experience
Clinical Workup
No major changes to standard
procedure
Things to note:
How well patient dilates
Is patient able to keep still during
procedure
33. Patient Experience
During procedure
Docking: Slight pressure from vacuum pressure
of interface (no pain or loss of vision)
During laser: A kaleidoscope of lights as the
procedure occurs
Immediate to One-Day Post-op
Same regimen as existing practices
Visual recovery may be faster because of
reduced ultrasound energy
Patient may notice slight haemorrhaging on the
conjunctiva
34. Contraindications
Femtocat is contraindicated in patients with corneal ring
and/or inlay implant(s)
In patients with severe corneal opacities, corneal
abnormalities, significant corneal edema or diminished
aqueous clarity that obscures OCT imaging of the
anterior lens capsule
Technical difficulties such as small pupil, deep orbit, very
shallow AC, dementia, tremor
? Paediatrics
35. Potential Advantages
Accurate capsulorhexis size, shape and centration may
allow for better positioning of all implant types.
Precise incisions to tens of microns: Astigmatism
control, infection control, iris prolapse reduction.
Reduction in phako power and time should give less
endothelial cell loss, decreased risk of corneal oedema
Numerous unique fragmentation pattern options allow
for treatment customization
Arcuate incisions
36. Disadvantages
Expensive ! Cost passed on to patient. “Value Add”
Increased complexity!
Increased duration!
No evidence as yet that the increased predictability
which this expensive complex longer procedure
provides actually delivers a clinically superior
result over current techniques to justify its wide
acceptance
Inapplicable in many demographic situations
38. Statements : True or False
Each step of current manual cataract surgery is
optimised , predictable and consistent
Femtosecond laser uses short wavelength UV light
Femtolaser cataract surgery is not contraindicated in
patients with small pupils, deep orbits or shallow
anterior chambers
38
Hinweis der Redaktion
Purpose of pres:Optometrist education on Catalys for their patients given by physicians
Circularity was measured as a function of disc size and area. A perfect circle has a circularity value of 1.0. The manual capsulorhexis had a mean circularity of 0.774 ± 0.146, while the laser capsulotomy had a mean circularity of 0.936 ± 0.038.
For both laser and manual arms of the study, the capsular tissue was collected intra-operatively so that shape and circularity could be measured. The excised discs, as pictured on this slide, were stained with Trypan Blue, photographed and converted to digital imagesSize accuracy was calculated as the deviation between intended diameter and observed diameter. The mean deviation for manual capsulorhexis was 339 ± 248 µm, whereas the mean deviation for laser capsulotomy was just 29 ± 26 µm (p<0.001). This represented over a 10 fold decrease in deviation from intended diameter with the laser. Moreover, the size variability (recorded as the standard deviation) from case to case was much reduced demonstrating a much more predictable and repeatable capsulotomy construction with the laser.
Since the femtosecond pulses are delivered optically through the cornea and anterior lens, the LenSx® Laser performs phacofragmentation without many of the mechanical effects and ultrasonic shockwaves/energy transmitted to the tissue by handheld phacofragmentation probes. The light pulses are focused to a small spot to achieve photodisruption of a tiny volume of tissue, a few microns in diameter, at the laser focus. A surgical effect is produced by scanning thousands of individual pulses in a specific pattern.There are two methods used for laser lens fragmentation – chop and cylinder. Each of these methods is customizable. For cataracts grade 0-2, the cylinder pattern is used enabling lens removal with only I/A and no phaco power. For higher grade cataracts, the chop pattern is preferred which greatly reduces manual manipulations as well as excessive phaco power and time
This section contains Catalys images that may be useful for the presenter as they put together their own presentation.
Speaking Points:There are 4 key steps to the Catalys procedure – Plan, Engage, Visualize & Customize, and Treat
Planning a treatment on the Catalys system is quick, intuitive and template-based.For each surgeon, templates for capsulotomy and lens fragmentation can be configured for commonly used treatment parameters.For example, in a large percentage of his cases, Dr. James Fleming centers his capsulotomy on the center of the scanned capsule (as determined by OCT) and uses a 6mm diameter optic. Instead of having to input the diameter and centration parameters on every case, a one click template can be utilized.
Liquid Optics is a novel interface that docks the patient to the system without corneal distortion or induced folds.The 13.5mm clear aperture of the suction ring component of the Liquid Optics Interface enables all cuts to be performed in a single dock.It provides a clear optical path for real-time video, OCT imaging and precise laser delivery.Because there is no corneal distortion, IOP rise is minimal.
In the Catalys procedure, the ocular surfaces are visualized by a proprietary, integrated Optical Coherence Tomography (OCT) system. The OCT is enhanced by sophisticated algorithms designed to ensure that the femtosecond laser pulses are delivered precisely to the intended location.Steps in the Integral Guidance process:Proprietary, 3D spectral domain OCT imaging system visualizes the ocular surfacesAlgorithms process the image, automatically and accurately detect surfaces, and create exclusion zones where the laser cannot fire (denoted in red on images at right)The surgeon’s treatment plan is then customized, based on the patient’s ocular anatomy and the precise orientation of the eyeAfter the surgeon confirms the customized treatment plan, the femtosecond laser is delivered precisely to the intended location, maintaining the exclusion zonesThe Integral Guidance Advantage:3D treatment customization enables procedure to be performed even when eye or lens is tilted relative to laser pathCan fragment lens deeply while maintaining adequate distance from posterior capsule Optimized for accuracy AND speed to enable precise incisions with minimal time under dock
Again emphasize that not much changes for clinical workup or post-surgical follow-up go over things to note
Emphasize that not much changes Pre-op or Immediate/One-Day Post-opMostly are minimal changes during the procedure