Femtocataract Refractive Cataract Surgery – Lens Based Refractive Surgery as an Alternative to LASIK
A 55-year-old female CEO presented for refractive surgical consultation at the Clarity Center with complaints of steadily declining uncorrected visual acuity with problems both at distance and near range. The patient had attempted soft contact lens wear but reported discomfort, poor lens tolerance and inadequate corrected acuity. Review of medical and past ophthalmic history was unremarkable. She expressed a desire for excimer laser vision correction either with LASIK or PRK.
On clinical evaluation vision was correctable to 20/25 OU with +4.25-1.00 X 155 OD and +3.75-1.50 X 160. With an add of +2.75 she saw J1+ at near. The anterior segment evaluation revealed a clear cornea with quiet anterior chamber and 1+ nuclear lens changes. Tear break up time was greater than 10 seconds and there was no staining with fluorescein installation. Fundus examination was unremarkable with 0.3 cups and normal maculas.
Wave scan evaluation confirmed a hyperopic pattern with astigmatism closely approximating her current spectacles with 3% higher order aberration OU.
A full review of treatment alternatives was presented to the patient with inherent associated benefits and risks. Options included PRK Custom surface treatment, LASIK or clear lens Femtosecond Refractive Laser Cataract Surgery (FRLCS). After a complete review of inherent benefits and risks the patient opted for Refractive Laser Cataract Surgery. A presentation of lens implant options was presented to the patient with a careful analysis of her treatment goals. It was explained that quality in desired outcome was well within reach with this new technology and that any necessary enhancements following surgery could be offered at the Clarity Center by means of surface excimer PRK or Femtosecond Laser Astigmatic Keratotomy. After personalized counseling at the center with our refractive surgery consultant the patient elected FRLCS with a multifocal lens implant and corneal astigmatic keratotomy. Careful biometric analysis was performed to assure lens power accuracy.
On the morning of surgery a treatment plan for the right eye was programmed into the Optimedica Catalys system with the laser treatment to include paired femtosecond arcuate astigmatic cuts in the steep corneal meridian, 4.5 mm capsulotomy and lens softening. Using a liquid interface the patient was docked with the laser without difficulty. OCT analysis allowed for excellent visualization of the lens assuring precise centration of capsulotomy and astigmatic cuts as well as providing a 500-micron safe zone above the posterior capsule. Corneal astigmatic cuts, anterior capsulotomy and lens softening were completed in an uneventful laser procedure prior to cataract extraction and lens implantation at the ESSI surgical center.
In the ESSI OR uneventful lens extraction with precise placement of lens implant requiring minimal phacoemulsion time. Following surgery, a well centered Restor multifocal lens was observed.
On her week one postoperative evaluation uncorrected acuity was 20/25 with J2 at near. The cornea was crystal clear with well placed 60-degree arcuate incisions. Lens implant was noted to be in excellent position. The patient was sent to schedule her second procedure for the following week.
Years of experience in excimer laser vision correction have been very instructive in revealing that certain refractive errors do not have outcomes as good as we would like to deliver for our patients. We have learned that hyperopic errors, especially over +3.00 are high on that list. Such hyperopic refractive treatments often require lengthy periods of recovery; provide final outcomes with unacceptable quality of vision, dry eye symptoms and a high incidence of regression approaching 30%. The advent of Femtosecond Laser Refractive Cataract Surgery has brought us a very safe alternative for such patients.
Lens based refractive surgery now represents a viable option for patients seeking vision correction. While clear lens extraction surgery might have been viewed as bringing an unsafe risk/benefit ratio in the past, the arrival of precise femtosecond laser technology has changed everything. Precise anterior capsulotomy now assures excellent lens centration and with it better function. Lens softening with the laser has allowed for a very impressive reduction of phacoemulsion time, reducing energy requirements by as much as 97% in some studies. This has allowed for rapid recovery of vision and a reduction of endothelial cell loss often accompanying phacoemulsification procedures.