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Robin G. Abell, MBBS,1 Peter E.J. Davies, FRANZCO,2 David Phelan, BSc,3 Karsten Goemann, PhD,4 Zachary E. McPherson, BMedSci,2 Brendan J. Vote, FRANZCO1
Objective: To compare the incidence of anterior capsular tears after femtosecond laser-assisted cataract surgery (FLACS) versus phacoemulsication cataract surgery (PCS) and to assess the ultrastructural features of anterior capsulotomy specimens (FLACS and PCS) using electron microscopy. Design: Prospective, multicenter, comparative cohort case series. Participants: Consecutive patients undergoing FLACS or PCS. Methods: A prospective cohort study of all patients (n 1626) undergoing FLACS or PCS by 2 surgeons from centers A and B was undertaken to compare the incidence of anterior capsule tears. Anterior lens capsules were collected by 4 surgeons from centers A, B, C, and D using 3 different commercially available femtosecond platforms, each with latest version upgrades. Lens capsule tissue was prepared for scanning electron microscopy (SEM) using a total of 10 samples for patients undergoing PCS, and 40 samples for patients undergoing FLACS. Main Outcome Measures: Incidence of anterior capsule tear and comparative ultrastructural features of capsular samples from both PCS and FLACS cases. Results: There was a signicantly increased rate of anterior capsule tears in the FLACS group (15/804 [1.87%]) when compared with the PCS group (1/822 [0.12%]; P 0.0002, Fisher exact test). In 7 cases, the anterior capsule tear extended to the posterior capsule. Because all cases had occurred in complete capsulotomy, the integrity of the anterior capsule was questioned in the FLACS group. Subsequent SEM sampling showed irregularity at the capsule margin, as well as multiple apparently misplaced laser pits in normal parts of the tissue. Aberrant pits were approximately 2 to 4 mm apart and occurred at a range of 10 to 100 mm radially from the capsule edge. Conclusions: Laser anterior capsulotomy integrity seems to be compromised by postage-stamp perforations and additional aberrant pulses, possibly because of xational eye movements. This can lead to an increased rate of anterior capsule tears, and extra care should be taken during surgery after femtosecond laser pretreatment has been performed. A learning curve may account for some of the increased complication rate with FLACS. However, the SEM features raise safety concerns for capsular integrity after FLACS and warrant further investigation. Ophthalmology 2014;121:17-24 2014 by the American Academy of Ophthalmology.
Continuous curvilinear capsulorrhexis (CCC) is one of the most integral steps of conventional phacoemulsication cataract surgery (PCS).1 It also is one of the most difcult steps for trainees to master.2 Variations in the size of the capsulorrhexis can result in aberrant intraocular lens (IOL) position, myopic or hyperopic shift, capsule brosis and contraction, or posterior capsule opacication.3e5 The size and shape of the capsulorrhexis therefore are key determinants in both the position and performance of the IOL.6 Inaccurate estimation of effective lens position is the largest cause of IOL power calculation error.7,8 With the increasing prevalence of toric, multifocal, and accommodating IOLs, the importance of customized IOL formulas with predictable effective lens position is paramount to superior refractive outcomes, which the femtosecond laser may allow. The increasing use of femtosecond lasers in cataract surgery has led to numerous recent studies of its efcacy and safety in performing anterior capsulotomy.9 Capsular complications after femtosecond laser-assisted cataract surgery (FLACS) were increased in an early study, which is
thought to be the result of the initial learning curve.10 However, complications were signicantly less in the subsequent series at the same facility (both studies performed with an earlier docking system of the commercial laser platform).9,10 Studies also have shown improved overlap, centration, size, and circularity of anterior capsulotomy with FLACS.11e13 Currently, early data suggest that more precise laser capsulotomy results in better visual and refractive outcomes when compared with PCS.14e16 Likewise, the strength of anterior capsulotomy after FLACS is improved in porcine eyes,17,18 but whether this equates to human eyes, particularly in the intraoperative clinical setting, remains to be seen. In this study, we prospectively evaluated the safety of FLACS by comparing the anterior capsule tear rates between PCS and FLACS. For clinicopathologic correlation, we also evaluated the integrity of anterior capsulotomies by observing capsular edge ultrastructure from 2 different laser platforms using high-denition scanning electron microscopy (SEM).
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Methods
Study Design
A prospective, nonrandomized, comparative cohort case series was carried out at 2 centers (centers A and B) in Australia using a commercially purchased femtosecond laser platform (Catalys Precision Laser; OptiMedica, Sunnyvale, CA) to evaluate the incidence of anterior capsule tear between conventional PCS and FLACS. A clinicopathologic correlation was made between anterior capsule tear rates and anterior capsular integrity by examining ultrastructural integrity of FLACS and PCS capsulotomies (from 4 centers: centers A, B, C, and D) using SEM. Data were collected prospectively on anterior capsule tear rates between FLACS and PCS at centers A and B for analysis commencing April 30, 2012, through June 7, 2013. The study was approved by the Tasmanian Human Research Ethics Committee and was conducted in accordance with the tenets of the Declaration of Helsinki and its subsequent revisions (2004).
Statistical Analysis
The data to be analyzed were imported into IBM SPSS software version 19 (IBM, Chicago, IL) and were examined with descriptive and frequency analyses. Categorical data were analyzed using the Fisher exact test. Differences were accepted as signicant at P < 0.05.
Results
Clinical Outcomes
A total of 1626 consecutive patients undergoing cataract surgery at 2 different centers (centers A and B) were included in this prospective study of the incidence of anterior capsule tears. There were 804 eyes in the FLACS group and 822 eyes in the PCS group. There was no difference in demographics or baseline characteristics between groups (Table 1). The incidence of anterior capsule tears in the FLACS group (n 15) was signicantly higher than that in the PCS group (n 1) (1.87% vs. 0.12%; P 0.0002). There was no signicant difference in incidence rates between centers A and B. Cases 1 through 8 were treated at center A, whereas cases 9 through 15 were treated at center B (Table 2). All FLACS cases occurred with complete capsulotomy. When available, videos of cases were reviewed to determine when the complication occurred (Table 2). None of the patients with an anterior capsule tear were determined to have risk factors for capsular complications after review of videos and retrospective review of preoperative clinical notes (Table 2). In 7 patients, the anterior capsule tear extended to the posterior capsule and required sulcus IOL implantation. Five of these patients had no vitreous loss, whereas the remaining 2 patients underwent an anterior and posterior vitrectomy, respectively.
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Variable Age Female sex (%) Cataract grade (PNS) BCVA Baseline keratometry (D) AC depth (mm) Axial length (mm)
AC anterior chamber; BCVA best-corrected visual acuity; D diopters; NS not signicant; PNS Pentacam Nuclear Staging. Data are mean standard deviation unless otherwise indicated.
Discussion
This prospective, multicenter study evaluated the safety of FLACS with regard to anterior capsule tears. We found a signicantly higher rate of anterior capsule tears in the FLACS group beyond the initial learning curve expected with the technology.9,10 Current published studies of FLACS technology have emphasized the benets of FLACS. Benets include lower phacoemulsication energy resulting in less corneal and macular edema, as well as uniform capsulotomy size and shape.13,14,21e23 The theoretical benets of uniform IOL position and reduced postoperative refractive error currently are being evaluated. Surgical centers worldwide are cautiously adopting current versions of this technology on the basis of early improvements and the results of early studies. Because published evidence for long-term benets is limited, many
Histopathologic Findings
A total of 50 anterior capsules from centers A, B, C, and D were examined using SEM. The integrity of the capsule edge was assessed at high magnication. Samples also were observed for anterior capsular tags and aberrant laser-induced pits or perforations internal from the capsule edge. Three laser samples, one from each laser platform (Catalys, LenSx, and LensAR), were found to have an anterior capsulotomy tag (Fig 1). All laser platforms had FLACS samples with apparently misplaced laser perforations apparent on high magnication (Fig 2). These perforations could be seen extending well inside the capsule edge on medium magnication (Fig 3). The
Tear Occurrence
154 AC tear before hydrodissection 186 AC/PC tear noted after nal nuclear segment removal No 254 AC tear noted after removal of phaco probe No 286 AC tear during hydrodissection No 301 AC tear noted during nucleus removal No 350 AC tear noted during I/A No 389 AC tear, NR Floppy iris 420 AC tear noted during nucleus syndrome removal Previous blunt 119 AC/PC tear noted at I/A trauma HSV scarring 152 AC/PC tear noted during nucleus removal No 155 AC/PC tear during nucleus removal No 199 AC/PC tear, NR No 229 AC/PC tear, NR No 250 AC/PC tear noted at IOL insertion No 302 AC tear during nucleus removal
AC anterior capsule; HSV herpes simplex virus; I/A irrigation and aspiration; IOL intraocular lens; NR not recorded; PC posterior capsule. Subjects 1 through 8 were treated at center A, and subjects 9 through 15 were treated at center B.
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Figure 1. A, Anterior capsule tag (white arrows) extending obliquely from the capsule edge (gray arrows) from the LenSx laser (Alcon, Inc., Fort Worth, TX) (original magnication, 1500). B, Anterior capsule tag (white arrows) some distance from the capsule edge from the Catalys laser (OptiMedica, Sunnyvale, CA) (original magnication, 300). These ndings may be consistent with eye movement during laser capsulotomy.
cataract surgery centers are awaiting further long-term studies before adoption.6 After initially positive results for other aspects of FLACS in our prospective comparative studies,14,19 our early data on capsular complication rates do not mirror other published studies.9 Evidence-based guidelines for PCS suggest that a capsule complication frequency of less than 2% should be achievable (Table 3).24 Our anterior capsular tear rate is less than this gure but does not compare with previous benchmarks for PCS at our centers (0.06% and 0.2%, respectively, for the 2 surgeons). Our third center, center C, collected data retrospectively and also found capsular complication rates that were higher than their personal phacoemulsication benchmarks (2.9% for FLACS vs. 0% for PCS), although with only 70 FLACS cases, this may reect greater inuence of a learning curve effect, as previously identied.9 Previous studies have not compared FLACS capsule complication rates with concurrent phacoemulsication capsule complication rates, unlike our study, which had prospective comparative cohorts. Within the FLACS group, none of the complicated cases were noted immediately before, during, or immediately after surgery to have risk factors such as weak zonules, shallow anterior chamber, small pupil, high vitreous pressure, or poor visibility during surgery.25,26 Roberts et al9 suggested
that anterior capsule tears are more likely to result from a microtag being stretched and torn during intracapsular manipulation. They recommended switching to high magnication and inspecting the capsular edge before proceeding to phacoemulsication. Acknowledging the presence of microtags seems to be important, although if present, awareness and caution may not be sufcient to prevent capsular complications. Currently, the only solution without a proper understanding of anterior capsule force dynamics after FLACS, however, is such cautious surgical maneuvers that avoid any stress on the anterior capsule. None of our cases seemed to occur because of focal attachments or tags. Similarly, 100% of our FLACS radial tear patients underwent a complete capsulotomy, many of which were free-oating procedures. Capsule specimens consistently showed ultrastructural features that may suggest a mechanical basis for weakness in capsular integrity induced by FLACS, independent of the laser platform used. During our study, we conducted SEM studies at 2 university centers using 4 different preparation techniques. Most capsule buttons were prepared in a fashion similar to that of a previous study.18 None of our FLACS samples resembled previously published images of femtosecond laser-cut capsules, despite identical preparation methods.18
Figure 2. A, Irregular structure of the capsule edge from the Catalys femtosecond laser (OptiMedica, Sunnyvale, CA). Note also the apparently misplaced laser pulses (white arrows) on the smooth surface of the anterior capsule measuring less than 2 mm across (original magnication, 10 000). B, Similar structure at the same magnication of the capsule edge from the LensAR laser (original magnication, 10 000).
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Figure 3. A, Catalys femtosecond laser (OptiMedica, Sunnyvale, CA) capsulotomy with multiple rows of misplaced laser pulses (white arrow) on the posterior surface of the anterior capsule extending from the capsule edge (black arrows), which in this picture is folded back on itself to reveal the underside of the capsule (original magnication, 900). B, LensAR laser (LensAR, Inc., Orlando, FL) capsulotomy with a row of misplaced laser pits approximately 35 mm from the capsule edge (original magnication, 600). C, Catalys femtosecond capsule edge that appears to have been cut in 2 distinct planes, perhaps created during subsequent passes of the laser capsulotomy, but each pass is slightly misaligned (original magnication, 10 000).
Previous images revealed only slight serrations or microgrooves in the capsule and were remarkably consistent with a cleanly cut edge. Our samples showed signicant microscopic postage-stamp perforations, suggesting that the capsulotomy created by FLACS is of the can-opener variety, albeit at a microscopic level. Laser-cut capsules frequently had tags and skip lesions, as well as regular lines of aberrant misred pits, presumably from microscopic xational movements of the eye. We observed that there was no difference in images obtained from before and after the latest software and hardware upgrades (including the Alcon LenSx SoftFit patient interface upgrade) for each of the laser platforms. A recent study used anterior segment imaging to track eye movements during the laser procedure.27 This study revealed movements of approximately 20 mm in the time it takes to perform anterior capsulotomy. The vacuum pressure used in the study was 500 mmHg using a liquid optics interface, which has been proven to result in only a small increase in intraocular pressure, while maintaining stability of the globe.27e29 We demonstrated that, even at this level of suction, eye movements actually may extend beyond 100 mm in the time it takes to perform the capsulotomy. This was evidenced by laser pulses creating pits in the anterior capsule at around 100 mm radially from the capsule edge. Multiple rows of these aberrant pits certainly could compromise the integrity of the capsule edge by creating a postage-stamp radial pattern for a tear to initiate
with adequate force. Reasons for eye movements to this degree may include inadequate suction or a oppy conjunctiva that still allows eye movement under adequate suction. Prior studies have shown that a capsulorrhexis performed using diathermy, can-opener, or postage-stamp perforations has less resistance to capsule tears than the smooth capsule edge created using CCC.30e34 Capsulotomy edges that are not smooth may disrupt the normal collagen microbrillar arrangement.32 In addition, the irregularities at the edges may act as focal points for the concentration of stress that would increase the probability of propagation and the development of capsular tear.35 Because the CCC edge preserves collagen arrangement, the limiting distension is reached when the elastic limit of the capsule is exceeded.32 Current studies of FLACS anterior capsulotomy have examined only porcine eyes, which are known to be more elastic than the human adult capsule and tend to resemble more closely a human pediatric anterior capsule.30,33 In fact, the rupture load and extensibility results for manual CCC found in recent FLACS porcine strength studies (comparing manual CCC with FLACS anterior capsulotomy) are much higher than those in existing in vivo porcine and human cadaver studies.17,36 Studies are required to assess the strength of FLACS capsulotomy in human cadaver eyes as well as the clinical setting in vivo. Most tears occurred with hydrodissection or during lens manipulations, suggesting that capsular stress
Figure 4. A, Edge treated with the Catalys femtosecond laser (OptiMedica, Sunnyvale, CA) is serrated, resembling a microecan-opener structure from the laser photodisruption, each estimated here to be just less than 2 mm across (original magnication, 10 000). B, Manually torn capsule (original magnication, 10 000).
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Figure 5. A, Jagged and undulating edge of the LenSx femtosecond laser (Alcon, Inc., Fort Worth, TX) capsulotomy (original magnication, 1100). B, LensAR (LensAR, Inc., Orlando, FL) femtosecond capsulotomy showing the jagged edge at closer magnication that consists of small focal tags (circled). Outward tags would correspond to a notch in the anterior capsule in vivo (original magnication, 1400). C, Manual capsulorrhexis showing a smooth and consistent edge (black arrows), which is at the same magnication as A (Original magnication, 1100).
may be more the result of expansive vector forces from gas and hydrodissection volumes rather than linear extensibility. It is unknown whether the improved circularity with FLACS is a factor dependent on equal distribution of forces after IOL implantation in the bag and resistance to tearing. Because the stress-strain and force-displacement relationships are nonlinear, it is difcult to determine the variables involved with alterations in the mechanical quality of the anterior capsule.37,38 Capsulorrhexis strength may vary as a function of capsulotomy size, reecting the variations in capsular thickness that occur as a function of eccentricity.32 Hence, the stronger anterior capsulotomy found with FLACS in some studies may be a function of its centration and optimal size. The microscopic postage-stamp perforations we observed in this study, however, may have an effect on force-displacement relationships and resistance to tearing in human adult eyes that has not been tested. In addition, intraoperative uidics and altered capsule stiffness may predispose patients to a greater risk of anterior capsular tear after FLACS because some cases were noted subincisionally on withdrawal of the phacoemulsication instrument probe after fragment removal. We believe that although femtosecond laser technology may be safer in some surgeons hands, this is not necessarily true for all surgeons and certainly depends on the benchmark against which one is measuring. We also cannot rule out individual variations in the performance of each laser platform. Deciencies in laser output energy or disruptions to the optical path of laser pulses may affect the quality and
Table 3. Summary of Anterior Capsule Tear Rates in the Current Literature
Authors Roberts et al9 Bali et al10 Woodeld et al39 Olali et al40 Unal et al41 Marques et al42 Muhtaseb et al43 Ng et al44 PCS average Year Rate, % (n) 2012 2012 2011 2007 2006 2006 2004 1998 0.31 (1300) 4 (200) 2.2 (691) 5.6 (358) 5.1 (296) 0.79 (2646) 2.8 (1441) 3.8 (1000) 2.32% Study Type Prospective (LCS) Prospective (LCS) Retrospective (PCS) Case series (PCS) Prospective (PCS) Retrospective (PCS) Prospective (PCS) Prospective (PCS) Level of Training Specialist Specialist Resident Specialist Resident Specialist Specialist Specialist
consistency of resultant biological photodisruption resulting from laser-induced optical breakdown. Variations in pulse energy and spot spacing between company platforms, which also are adjustable by the user, also may affect the architecture of the capsulotomy edge. Optimal laser spot spacing and power settings remain to be determined. With demonstrated improvement in surgery outcomes, the small risk of complications may be acceptable; however, further studies are required to evaluate which surgical techniques, laser platforms, surgeons, and patients may benet from the technology. Patients should be aware they belong to a learning cohort for the surgeons initial cases. Surgeons need to take care when implementing this technology into their practice. There is a signicant learning curve associated with femtosecond laser technology that may extend beyond the initial cases. Laser anterior capsulotomy integrity may be compromised when compared with phacoemulsication capsulotomy because of aberrant pits creating postage-stamp perforations during patient eye movements. In our study, this can lead to an increased rate of anterior capsule tears, and extra care needs to be taken during surgery by surgeons implementing this technology.
Acknowledgment. The authors would like to acknowledge Dr. Guy Bylsma and Dr. Graham Fraenkel for the collection of additional capsulotomy samples.
References
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7. Ceki O, Batman C. The relationship between capsulorrhexis size and anterior chamber depth relation. Ophthalmic Surg Lasers 1999;30:18590. 8. Norrby S. Sources of error in intraocular lens power calculation. J Cataract Refract Surg 2008;34:36876. 9. Roberts TV, Lawless M, Bali SJ, et al. Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases. Ophthalmology 2013;120:22733. 10. Bali SJ, Hodge C, Lawless M, et al. Early experience with the femtosecond laser for cataract surgery. Ophthalmology 2012;119:8919. 11. Krnitz K, Takcs , Mihltz K, et al. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg 2011;27:55863. 12. Krnitz K, Mihltz K, Sndor GL, et al. Intraocular lens tilt and decentration measured by Scheimpug camera following manual or femtosecond laserecreated continuous circular capsulotomy. J Refract Surg 2012;28:25963. 13. Nagy ZZ, Krnitz K, Takcs AI, et al. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg 2011;27:5649. 14. Abell RG, Kerr NM, Vote BJ. Toward zero effective phacoemulsication time using femtosecond laser pretreatment. Ophthalmology 2013;120:9428. 15. Filkorn T, Kovcs I, Takcs A, et al. Comparison of IOL power calculation and refractive outcome after laser refractive cataract surgery with a femtosecond laser versus conventional phacoemulsication. J Refract Surg 2012;28:5404. 16. Lawless M, Bali SJ, Hodge C, et al. Outcomes of femtosecond laser cataract surgery with a diffractive multifocal intraocular lens. J Refract Surg 2012;28:85964. 17. Auffarth GU, Reddy KP, Ritter R, et al. Comparison of the maximum applicable stretch force after femtosecond laser-assisted and manual anterior capsulotomy. J Cataract Refract Surg 2013;39:1059. 18. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011;37:118998. 19. Abell RG, Kerr NM, Vote BJ. Femtosecond laser-assisted cataract surgery compared with conventional cataract surgery. Clin Experiment Ophthalmol 2013;41:45562. 20. Worthen DM, Wickham MG. Scanning electron microscopy tissue preparation. Invest Ophthalmol 1972;11:1336. 21. Takcs AI, Kovcs I, Mihltz K, et al. Central corneal volume and endothelial cell count following femtosecond laser-assisted refractive cataract surgery compared to conventional phacoemulsication. J Refract Surg 2012;28:38791. 22. Nagy ZZ, Ecsedy M, Kovcs I, et al. Macular morphology assessed by optical coherence tomography image segmentation after femtosecond laser-assisted and standard cataract surgery. J Cataract Refract Surg 2012;38:9416. 23. Ecsedy M, Mihltz K, Kovcs I, et al. Effect of femtosecond laser cataract surgery on the macula. J Refract Surg 2011;27: 71722. 24. Lundstrm M, Behndig A, Kugelberg M, et al. Decreasing rate of capsule complications in cataract surgery: eight-year study of incidence, risk factors, and data validity by the Swedish National Cataract Register. J Cataract Refract Surg 2011;37:17627. 25. Palanker D, Nomoto H, Huie P, et al. Anterior capsulotomy with a pulsed-electron avalanche knife. J Cataract Refract Surg 2010;36:12732. 26. Coelho RP, Paula JS, Rosatelli Neto JM, Messias AM. Capsulorrhexis rescue after peripheral radial tear-out: quick-pull technique. J Cataract Refract Surg 2012;38:7378.
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Central Sciences Laboratory, University of Tasmania, Hobart, Tasmania, Australia. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article. Correspondence: Brendan J. Vote, FRANZCO, Launceston Eye Institute, 36 Thistle Street West, Launceston, Australia 7250. E-mail: eye.vote@bigpond.net.au.
Newcastle Eye Hospital Research Foundation, Newcastle, New South Wales, Australia. Electron Microscopy Unit, University of Newcastle, Callaghan, New South Wales, Australia.
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