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Femtosecond Lasers in Ocular Surgery

Alexander J. Kelly University of North Carolina at Charlotte

Outline of Topics
Introduction Corneal vs Cataract Surgery Basis of Pulsed Lasers Methods Reason for Ultrashort Pulse Procedure for Corneal Surgery Results Femtosecond vs Keratome Integration in Practice Further Improvement Conclusions

A femtosecond is to 1 sec is as 1 sec to 31.7 million years Femtosecond lasers have broad range of applications Difference between corneal surgery and cataract surgery?


Laser Fundamentals
Bandwidth of operation Gain medium and mirrors 1= 2L Constructive interference Longitudinal modes 2= L q = 2 L/ q Values of q around 105 to 106 3= L c/2nL Mode-locking Pulses can be as short as several femtoseconds

Why Ultrashort Pulse?

Cornea does not absorb near-infrared radiation Creates plasma under surface Pulses are short and precise Does not affect surrounding tissue Minimize damage

Characteristics: Neodymium-glass oscillator Wavelength: 1053 nm (infrared) Spot Size: 3 1 m

Corneal Surgical Procedure

Series of ultrashort pulses (3 1 m diameter) Photodisruption Guidance of imaging device Creation of a hinged circular flap

http://www.lasikguider.com/2010/01/how-all-laser-bladeless-lasik-is.html http://www.attiko.eu/en/laser_myopia.html http://ohioeye.com/wp-content/uploads/2013/02/LASIK-Flap.jpg

LASIK Surgery Study

Femtosecond laser (IntraLase Corp.) Desired flap thickness (m) 130 Keratome 1 (Moria CB) 130 153 26 59 to 210 9.6% 71% 73% Keratome 2 (Hansatome) 180 156 29 25 to 250 7.7% 66% 74% Mean flap thickness 114 14 SD (m) Range (m) Loose Epithelium *20/20 UCVA rate **0.5D MRSE rate 78 to 155 0% 67% 91%

* UCVA = Uncorrected Distance Visual Acuity. Patients that had 20/20 vision or better after 3 months. ** MRSE = Manifest Refractive Spherical Equivalent. Patient eyes within 0.50 diopters of attempted correction after 3 months.
G.M. Kezirian, K. G.Stonecipher, Comparison of the IntraLase femtosecond laser and mechanical kertomes for laser in situ keratomileusis, J. Cataract Refract. Surg. 30(4), 804811(2004)

Cataract Surgery Study

Complications Suction breaks Group 1 (n = 200) 2.5% Group 2 (n = 1300) 0.61% 1.23% 1.62% 0.31% 0.31% 0% P value 0.023 < 0.001 < 0.001 < 0.001 < 0.001 < 0.001 Pupillary constriction 9.5% Anterior capsule tags Anterior radial tears Posterior capsule tears Posterior lens dislocation 10.5% 4% 3.5% 2%

T.V. Roberts, M. Lawless, S. J. Bali, C. Hodge, G. Sutton, Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases, Ophthalmol. 120 (2), 227 233 (2013)

Non-Planar Incisions
Current method: clear corneal incision higher risk of gaping wounds Positional spikes and conical incisions Benefits: Repositioning, stability, healing

http://www.healio.com/ophthalmology/journals/osli/%7B8f35c33d-4c42-4779-afbb-247f776d1372%7D/architectural-analysis-of-clear-corneal-incision-techniques-in-cataract-surgery-using-fourier-domain-oct J. B. Jonas, U. Vossmerbaeumer, Femtosecond laser LASIK flap preparation with conical incision and positional spikes, J. Cataract Refract. Surg. 30(5), 1107-1108 (2004).

Non-invasive and versatile Avoid dangers and risk of a bladed tool Potential to develop better and safer outcome

Picture Credits

http://www.attiko.eu/en/laser_myopia.html http://www.davidorf.com/los-angeles/corneal-transplant.htm http://www.healio.com/ophthalmology/journals/osli/%7B8f35c33d-4c42-4779-afbb-247f776d1372%7D/architecturalanalysis-of-clear-corneal-incision-techniques-in-cataract-surgery-using-fourier-domain-oct http://www.lasikguider.com/2010/01/how-all-laser-bladeless-lasik-is.html

http://www.davidorf.com/los-angeles/corneal-transplant.htm http://www.lasikdallas.net/cataract-surgery-dallas/