The benefits of a pre-loaded IOL delivery system

www.eyeworld.org Capitalize on advancedtechnology for today's surgeon

2 0 1 1 A S C R S • A S O A S a n D i e g o S h o w D a i l y S u p p l e m e n t Supported by Alcon Inc.

Surgeon says IOL injectorsystem is critical to pre-serving lens quality andpreventing complications

For years, surgeons’ interestin foldable IOLs has re-volved around their abilityto create small incisionsand implant lenses in a

compact way in order to minimizeinduced astigmatism. However, fold-ing IOLs led to important considera-tions.

What is the best way to insert afolded lens? How can the surgeonminimize lens damage during thefolding and insertion process? If aninjector system is used, how can thesurgeon minimize variability in han-dling and loading the IOL?

Donald Serafano, M.D., in pri-vate practice, Complete Eye Care Associates, Los Alamitos, Calif., andassociate clinical professor of oph-thalmology, University of SouthernCalifornia, has strong views on thesematters. He believes that it’s criticalto properly insert the IOL to pre-serve its pristine condition.

“We occasionally see damagedlenses because the surgeon didn’t

match the appropriate inserter withthe IOL,” Dr. Serafano said.

Dr. Serafano recommended theAcrySert C preloaded IOL injector(Alcon, Fort Worth, Texas). Impor-tantly, the injector is custom de-signed to implant the AcrySof IQIOL (Alcon), he said. AcrySof IQIOLs provide excellent visual per-formance based on proven func-tional vision even in the mostchallenging conditions.

There’s well thought-out tech-nology behind the AcrySert C devicethat supports a worry-free IOL injection for every procedure, Dr.Serafano said.

“Right now, for most lenses inthe operating room, three thingshave to be opened,” Dr. Serafanoexplained. “We have to open an in-sertion device, a cartridge, and alens implant. We have to take thelens implant, load it into a car-tridge, and load that into an inser-tion device. But imagine if we couldopen a packet and all three of thoseitems are already assembled andready to go.”

What this does is eliminate variables such as who on staff istrained to properly load a lens. “WithAcrySert C, the operating room staffdo not have to be experts in lens

loading,” Dr. Serafano said.Regardless of who handles the

AcrySert C system initially, a sur-geon can be sure that when he orshe advances the plunger for IOL in-sertion, the lens will be free of anymarks caused by mishandling.

The AcrySert C delivery systemhas other advantages over previousinsertion devices. One relates toplunger resistance.

Higher diopter IOLs are actuallyslightly thicker lenses, and theselenses sometimes advance withmore resistance. However, if a sur-geon advances them with too muchforce, they could inject too quicklyinto the anterior chamber, causingiris damage or breaking through theposterior capsule.

This problem is solved with theAcrySert C delivery system, Dr. Serafano said. Resistance is actuallybuilt into the plunger itself.

“Whether a 10-diopter lens or30-diopter lens is being used, resist-ance is the same for the surgeon,”Dr. Serafano said. “We don’t have toworry about feeling a differenceevery time we insert the lens andbeing unsure of how hard to ad-vance the plunger. I think this is anexcellent innovation.”

Dr. Serafano said that it’s easy touse the AcrySert Csystem. “The AcrySofIQ can fit comfort-ably through asmaller incision sizedue to the small di-ameter of the noz-zle.”

The plunger de-sign is optimal, hesaid. “The plungertip is designed togive a consistentfold to the haptics,”Dr. Serafano said.“This should preventany override or un-derride on the IOL,which sometimeshappens with differ-ent plungers.”

Surgeons may

“With AcrySert C,the operating roomstaff do not have to be experts inlens loading”

Donald Serafano, M.D.

continued on page 3The AcrySert C preloaded IOL delivery system

This supplement was produced by EyeWorld under an educational grant fromAlcon.

Copyright 2011 ASCRS Ophthalmic Corporation. All rights reserved. The views expressed here do not necessarily reflect those of the editor, editorial board, or the publisher, and in no way imply endorsement by EyeWorld or ASCRS.

2 EW San Diego 20112 Monday, March 28, 2011

LenSx Laser technology has value inthe ophthalmic practice, surgeon says

New femtosecond cataractlaser provides precisionand reproducibility

Maybe the biggest newsin cataract last yearwas the Food andDrug Administration’sapproval of the fem-

tosecond cataract laser. Femtosecondlasers have improved the safety ofrefractive surgery and reduced surgi-cal times, and it makes sense thatwhat the femtosecond laser did forrefractive procedures, it would beable to do for cataract surgery, ac-cording to Richard L. Lindstrom,M.D., adjunct professor emeritus,department of ophthalmology, Uni-versity of Minnesota, founder, Min-nesota Eye Centers, Minneapolis,and associate director, MinnesotaLions Eye Bank, Bloomington.

“The LenSx Laser (Alcon, FortWorth, Texas) as applied to cataractsurgery will provide some of thesame benefits that it did for cornealrefractive surgery,” he said. “For thefirst time, we were able to increasethe reproducibility of the procedurefrom one surgeon to another andfrom one surgical case to another.”

Refractive corneal surgery withthe introduction of femtosecondLASIK “took a significant leap in im-provement” from manual microker-atomes, Dr. Lindstrom said. “Ibelieve the femtosecond cataractlaser will improve the performanceof the surgeon doing cataract sur-

gery as it replaces many of the man-ual steps in traditional cataract sur-gery.”

For instance, he cited an analy-sis by Guy Kezerian, M.D., thatfound 55% of patients are within 0.5D of emmetropia after cataract sur-gery, and the same percentage hassuccessfully eliminated astigmatism.

“In LASIK, 95% of patients arereaching target refraction,” Dr. Lindstrom explained. “We’re tryingto get cataract surgery to the level ofLASIK, and it’s clear we cannot getthere with manual approaches.”When surgeons attempt to deliveroutcomes within 0.5 D of target, re-producible incisions and capsu-lorhexis become the keycomponents, he said. The LenSxLaser will be able to offer patientsand surgeons enhanced precisionand reproducibility compared tomanual procedure steps, potentiallyimpacting the ability to account forthe clinical effects of the incisionsthemselves, Dr. Lindstrom said.

The LenSx Laser is an optical co-herence tomography (OCT) image-guided femtosecond laser thataddresses the first three steps ofcataract surgery: incisions, includingarcuate; capsulotomy; and nuclearfragmentation. Cortical removal andIOL insertion techniques remain thesame.

Safety advantagesSome issues facing all cataract sur-geons include spherical error and re-producible lens positions, which tiesinto reproducible capsulorhexis, Dr.Lindstrom said. The laser capsulo-tomy reduces the risks of radial tearsand posterior capsular ruptures dur-ing the creation of the anterior cap-sulorhexis, Dr. Lindstrom added,although there is nothing publishedin the literature on the topic yet. Al-though most surgeons do “fairlywell with manual techniques,” thefemtosecond cataract laser can re-produce capsulorhexis to within1/10 of a millimeter, he said.

Some surgeons are also usingthe laser to soften the nucleus. Moredamage is inflicted on the cornealendothelium with harder cataracts,and ultrasound times increase aswell. Using the femtosecond laser tosoften the nucleus helps avoid thosesituations, Dr. Lindstrom said.

“We’d like to move to only vac-uum-based lens aspiration with asmall amount of ultrasound assis-tance,” he said. “This laser lets us

have routine +1 cataract removalsinstead of +2, +3, or even +4. Thelaser inadvertently gives us a safersurgery.” Dr. Lindstrom noted man-ual techniques produce “quite a dif-ference in outcomes from onesurgeon to another. Femtosecondtechnology will increase the repro-ducibility among surgeons.”

For instance, Dr. Lindstrom said,although cataract surgery is safe,there is a higher complication ratein cataract surgery compared toLASIK (about five times higher).About 5% of eyes that undergocataract surgery have a capsule tearand/or vitreous loss, he said, basedon his own assessment of vitreouspacks sold. Even within a single op-erating environment, rates can differwildly—he cited one ambulatorysurgery center where vitreous lossrates ranged from 0.8% to 21%.

“Vitreous loss should be at 1%or less, and we’re not achievingthat,” he said.

Limited obstaclesDr. Lindstrom said incorporating thefemtosecond laser into a cataractpractice will likely increase the timeof the surgery (although not bymuch) and will increase the cost ofthe procedure. Because so manybaby boomers are willing to pay forenhanced quality of life, are affluentenough, and expect to share in thecost of the surgery, Dr. Lindstromdoes not believe these are insur-mountable obstacles.

The femtosecond laser will allowsurgeons “to charge for the technol-ogy, just like we do for refractive sur-gery. Today’s baby boomer cataractpatients have a refractive surgeryoutcome goal,” Dr. Lindstrom said,and they are willing to pay for en-hanced safety and better perceivedoutcomes.

“One thing to keep in mind isthat the patients of the future arethe baby boomers who overwhelm-ingly accepted contact lens technol-ogy and refractive surgery to ridthemselves of spectacles,” he said,which suggests a patient base al-ready familiar with laser surgery.

In short, he said, the precisionoffered by the femtosecond cataractlaser technology is designed to havebenefits for the doctor, the patients,and the ophthalmic practice.

Contact informationLindstrom: 952-567-6051,rllindstrom@mneye.com

“It makes sensethat what the

femtosecond laserdid for refractive

procedures, it would be able to do for cataract

surgery”

Richard L. Lindstrom, M.D.

The LenSx Laser

EW San Diego 2011 3

wonder if a mistake can be made inthe lens delivery process using thissystem. “If you forget any step alongthe way, the lens is not able to bedelivered,” Dr. Serafano said.

For instance, if a surgeon forgetsto fill the AcrySert C injector withviscoelastic, but he or she pulls offthe lens stop and advances theplunger, the implant will not ad-vance, Dr. Serafano said.

“There will be too much resist-ance between the lens implant andnozzle,” he said. “It’s impossible toadvance the lens that way.”

Other lens injection systems re-quire cleaning and sterilization.

AcrySert C does not. It’s a single-usedevice, entirely disposable.

“We once had a problem withtoxic anterior segment syndrome(TASS),” Dr. Serafano said. “Thecauses were tracked down and a lotwere found to be related to instru-ments that had any kind of cannulathat was not cleaned properly. Theywere sterilized and reused, but therewas a toxic substance formed fromthe residue of whatever was in thecannula and subsequently sterilized.An acute inflammatory response oc-curred.”

All the while, the original rea-son to implant foldable IOLs in the

Capitalize on advanced technology for today's surgeon

Putting Intelligent Phaco to the test

continued from page 1

“IP accentuatesthe efficiency ofthe OZil platformby eliminating theneed to ‘blend’ in

longitudinal ultrasound and by

automaticallyadding in short

pulses of longitudinal energy

only whenneeded”

Terry Kim, M.D.

Surgeon explains themechanism and benefits of OZil IP

If surgeons have any doubtabout using the INFINITI VisionSystem with OZil (Alcon, FortWorth, Texas), especially withthe Intelligent Phaco (IP) soft-

ware addition, Terry Kim, M.D.,professor of ophthalmology, DukeUniversity School of Medicine, anddirector of fellowship programs,Duke Eye Center, Durham, N.C., rec-ommended performing the follow-ing procedure as a test.

“During cataract surgery on adense lens, such as a 3+ nuclear scle-rotic cataract, divide the nuclear ma-terial into four quadrants using yourusual technique of divide-and-con-quer, pre-chop, or chop,” said Dr.Kim. “Then go ahead and emulsifythe first two quadrants using 100%torsional ultrasound without IP acti-vated. When you’re finished, turn IPon and emulsify the last two quad-rants with IP activated. You will beable to see and feel the difference interms of the enhanced efficiency inlens removal.”

Dr. Kim said that OZil IP repre-sents an advancement in the man-agement of phaco energy whereshort pulses of longitudinal ultra-sound are automatically added toOZil torsional ultrasound when apreset vacuum threshold is met. Thisfeature enhances OZil ultrasound bykeeping the lens material at the idealshearing plane of the phaco tip andincreasing followability by not al-lowing occlusion of the phaco tip tooccur. As a result, the IOP fluctua-

tions in the eye are reduced andpost-occlusion surge is essentiallyeliminated. The software automati-cally manages this ultrasound powermodulation so that it becomes aseamless event with minimal effortfrom the surgeon, according to Dr.Kim.

“OZil was an advance in ultra-sound technology where the side-to-side shearing motion of the phacotip, as opposed to traditional front-to-back motion of longitudinal ul-trasound, was found to be moreefficient in phacoemulsification byreducing repulsion of lens material,improving followability, and stabiliz-ing the anterior chamber. The OZilIP software accentuates the effi-ciency of the OZil platform by elimi-nating the need to ‘blend’ inlongitudinal ultrasound and by au-tomatically adding in short pulses oflongitudinal energy only whenneeded, which becomes clinicallyapplicable not only in routine casesbut also in denser lenses and othercomplex phaco cases,” Dr. Kim said.

Dr. Kim recommended using theOZil IP default settings to start, al-though they are customizable as thesurgeon becomes more comfortablewith the technology. For the major-ity of cases, Dr. Kim uses the defaultOZil IP settings of 95% vacuum limitthreshold, phaco pulse width of 10ms, and a longitudinal/torsionalratio of 1.0. With Dr. Kim’s phacosettings of 100% linear torsional and0% longitudinal ultrasound power,350 mm Hg vacuum limit, 35 cc/min of aspiration flow rate, and abottle height of 95 cm H2O, each ac-tivation of the OZil IP mode will de-liver up to twenty 10 ms-long pulses

of longitudinal ultrasound (for amaximum total of 200 ms) everytime the vacuum exceeds 332 mmHg (95% of 350 mm Hg).

“All of this translates to in-creased phaco efficiency with morestable anterior chambers and a safethermal profile. OZil torsional ultra-sound will be a no-brainer for rou-tine cases and will be a helpfulattribute for the more complex casesthat involve denser lenses, shallowanterior chambers, loose/brittlezonules, and small pupils. In all ofthese scenarios, we want to maxi-mize the efficiency of phacoemulsifi-cation, minimize the turbulence inthe anterior chamber, decrease thestress on the capsule, zonules, andiris, and reduce the trauma to thecorneal endothelium,” Dr. Kim said.

Given his experience as a micro-incisional cataract surgeon, Dr. Kimadvocated the use of OZil IP forsmall-incision cataract surgery. “Wehave been able to show some clini-cal benefits of using OZil torsionalultrasound in micro-incision (2.2mm) versus standard-sized cornealincisions (2.8 mm) in terms of lowercumulative dissipated energy (CDE,which refers to ultrasound energyuse) and better endothelial cellcounts,” said Dr. Kim.1 “Now there isclinical evidence to support the en-hanced safety and efficiency ofadding OZil IP to OZil torsional ul-trasound.” In this study, the use ofIP resulted in lower CDEs (by 37%)and shorter total ultrasound times(by 33%) in cataract surgeries per-formed with OZil IP versus OZil tor-sional phacoemulsification alone.This difference was even more no-ticeable in denser lenses where clog-

continued on page 4

first place is preserved. “The incisionis more predictable as it getssmaller,” Dr. Serafano said. Althoughhe doesn’t believe any incision isastigmatically neutral, efforts tomake incision sizes smaller—such asthrough foldable IOLs—have helpedto reduce unwanted effects of in-duced astigmatism.

Hence, Dr. Serafano believesAcrySert C is a step in the right di-rection as it combines the benefit ofan efficient pre-loaded device withthe AcrySof IQ technology.

Contact informationSerafano: serafano@gte.net

4

Dr. Masket says IP deliversthe best combination oftorsional and longitudinalultrasound

Intelligent Phaco (IP) is a criti-cal part of a trinity of pha-coemulsification innovation,according to Samuel Masket,M.D.,

clinical professor of ophthalmology,Jules Stein Eye Institute, David Gef-fen School of Medicine, Los Angeles.

“There are three key parts of theINFINITI Vision System [Alcon, FortWorth, Texas],” Dr. Masket said. “Thefirst is OZil, making phacoemulsifica-tion a more efficient cutting tool. Itchanged the landscape for phaco.Then there’s the INTREPID FMS [Fluidics Management System],which allows for fluidic stability.Then came the concept for IP, whichis a software modification. Each ofthese adds to the continuum for im-provement in chamber stability and

cutting performance.”Dr. Masket explained that IP en-

ables the INFINITI to incorporatenot only the OZil torsional side-to-side oscillating ultrasonic movementthat maintains the nucleus at thetip, but also pulses of longitudinalultrasound to help clear the tip andprevent system occlusion.

In the default IP setting, if 95%of the vacuum limit is achievedwhile working with torsional phaco,a 10 millisecond longitudinal burstof phaco is automatically induced.

These settings are customizable.“You can choose to have IP kick inanywhere between 90% to 100% ofthe vacuum limit,” Dr. Masket said.“Five to 20 milliseconds are also al-lowable.

“Because this software modifica-tion has been well received, I nolonger exhibit any tendency forclogging,” Dr. Masket said.

There are real benefits to usingthe OZil torsional handpiece with afraction of longitudinal ultrasoundcompared to competitor systems

with 100% ultrasound, Dr. Masketsaid.

“Recently I used one of theother machines that does not haveOZil and only has longitudinalphaco,” Dr. Masket said. “While itdoes cut well, the nuclear chatter,which is the tendency of longitudi-nal, is very real.”

That lens chatter, which in-volves the repulsion of lens materialby the longitudinal movement, cancreate inefficiencies and more cumu-lative dissipated energy (CDE), Dr.Masket said.

“My personal CDE dropped sig-nificantly when I went to OZil,” Dr.Masket said. “The torsional move-ment cuts lens material moving inboth directions. Longitudinal onlycuts going on the forward stroke.Half of the movement is wasted withlongitudinal.”

It’s important to consider theINFINITI Vision System holistically,with OZil, the INTREPID system,and IP as parts that make a refinedwhole device, Dr. Masket suggested.

EW San Diego 20114

“IP prevents total occlusion ofthe tip, allows forclearing of the

material from thetip, and helps holdthe nucleus at the

tip for more efficient

emulsion”

Samuel Masket, M.D.

continued on page 5

continued from page 3

ging of the phacoemulsification tipwas prevented with IP.2

“The INFINITI system is builtaround the concepts of customiza-tion and integration,” Dr. Kim said.“OZil IP can be customized so thatthe surgeon can tailor his or her set-tings for virtually any phaco sce-nario. OZil works in concert withthe INTREPID micro-coaxial system,which is specifically developed formicro-incisional cataract surgery. I

have been very interested in the po-tential advantages of 2.2-mm inci-sions, both in terms of reducedastigmatism and improved woundstability.”

References1. Berdahl JP, Jun B, DeStafeno JJ, Kim T.Comparison of a torsional handpiece throughmicroincision versus standard clear cornealcataract wounds. J Cataract RefractSurg. 2008;34(12):2091-5.

2. Titiyal JS, Ghatak U, Sharma N. Comparisonof Phacoemulsification using Torsional Ultra-sound (OZil) with and without Intelligent Pha-coemulsification. Poster presented at theAmerican Academy of Ophthalmology AnnualMeeting; October 18, 2010; Chicago, Ill.

Contact informationKim: kim00006@mc.duke.edu

Bevel-down vertical “quick chop.” The fluidic part of theoverlay to the right indicates that occlusion has been achievedand there is no outflow. The phaco power overlay to the leftindicates that only torsional energy is deployed. These condi-tions are ideal for maintaining a purchase on the nucleus,facilitating chop maneuvers

Segment removal in IP mode. Note on the overlay to the rightthat there is fluid outflow as there is no occlusion. Also notethat the phaco power overlay to the left indicates that bothlongitudinal and torsional emulsification have been triggeredby the IP software

Source: Samuel Masket, M.D.

Surgeon says IP provides best of both ultrasound worlds

Monday, March 28, 2011

Surgeon is impressed by new laser

Shortly after StephenSlade, M.D., Slade &Baker Vision Center,Houston, received the firstWaveLight FS200 Fem-

tosecond Laser (Alcon, Fort Worth,Texas) in the United States, he wasimpressed with the results.

“It was fast, creating a flap in amatter of 6 seconds,” said Dr. Slade.“I was impressed with it. The firstpatient, a myope, was 20/20 thenext day, and I have been using thelaser ever since.”

This laser is at the forefront offemtosecond innovation, accordingto Dr. Slade. He has only had it for acouple of months, so he doesn’t yethave 3-month clinical results tospeak of.

What he does have are somememorable initial impressions. “Itmakes a beautiful flap,” Dr. Sladesaid. “It also integrates well with theWaveLight Eye-Q Excimer Laser(Alcon), with a swinging patient bedthat can go back and forth.”

FS200 designed for the Eye-Q The fact that the FS200 was made bythe same group as the WaveLightEye-Q Excimer Laser gave Dr. Sladehigh hopes that the femtosecondwould be equally as good. He hasn’tbeen disappointed. “I was impressedwith the quality of the flap andspeed of the laser,” Dr. Slade said.

EW San Diego 2011 5Capitalize on advanced technology for today's surgeon

Tracking the FS200 FemtosecondLaser from research to practice

Dr. Slade suspects that some ofthe first users of the FS200 will beexisting WaveLight Eye-Q users. Cur-rently the laser is indicated for creat-ing LASIK flaps and penetratingkeratoplasty.

Femtosecond lasers have come along way from their humble begin-

“The FS200 wasfast, creating

a flap in a matterof 6 seconds. I was

impressed with it”

Stephen Slade, M.D.

For instance, both the IntrepidFMS and IP components help reducepost-occlusion surge, Dr. Masketsaid.

“One of the advantages of INTREPID FMS is reducing post-oc-clusion surge,” Dr. Masket said.“With IP, because it doesn’t allow oc-clusion with full vacuum, it reducesthe tendency for post-occlusionsurge.”

Reducing surge makes it safe towork bevel-down to subdivide nu-clear material, Dr. Masket said,which is his preference.

“I work bevel-down and I feelsafe doing so,” Dr. Masket said. Dr.Masket said working bevel-down al-lows him to be more efficient atachieving and maintaining purchaseon the nucleus for the purpose ofchopping.

“An analogy would be slicing aturkey at Thanksgiving,” Dr. Masketsaid. “Unless you have a firm pur-chase with the fork, it’s almost im-possible to slice the turkey with aknife.”

Still, the original concept inphacoemulsification was to use the

phaco needle bevel-up. “Historically,there wasn’t a fluidics system thathad surge protection,” said Dr. Masket, adding that INTREPID FMSmakes bevel-down surgery safer.

The INTREPID FMS has lowcompliance tubing and cassette thatimprove fluidics as well by givingsurgeons more stable anterior cham-bers.

It allows surgeons to use theirown custom phacoemulsificationsettings—whether with small oreven smaller incisions, high or evenhigher vacuum—and still performsurgery safely and comfortably.

Dr. Masket’s other surgical pref-erences give insight into the utilityof the OZil handpiece. “In order toobtain the true value of OZil, youneed to have an angulated tip,” Dr.Masket said. “The tip I use is one designed by Robert Osher, M.D.,which is a reverse Kelman, 12-degreeangle, mini-flared tip.”

This tip optimizes the side-to-side shearing motion of torsionalphacoemulsification, which againprevents chatter and minimizesCDE. “I don’t have to chase the lens

material with OZil,” Dr. Masket said.“It comes to me.”

According to Alcon, this im-proved followability is more conven-ient and it makes surgery moreefficient.

Specifically, the company notes,the lack of repulsion increases fol-lowability and allows surgeons tolower their fluidic parameters with-out sacrificing surgical efficiency.

At the end of the day, Dr. Masket said the INFINITI Vision System “makes surgery easier for agreater number of surgeons.” TheOZil handpiece provides an ad-vancement in ultrasound qualitywhile IP optimizes that evolution,he said.

“The IP software modificationprevents total occlusion of the tip,allows for clearing of the materialfrom the tip, and helps hold the nu-cleus at the tip for more efficientemulsion,” Dr. Masket said.

Contact informationMasket: 310-229-1220, avcweb@aol.com

continued on page 7

continued from page 4

FS200 designed for the Eye-Q

6

FS200 femtosecond preserves patient eyehealth, surgeon says

Femtosecond lasers havebeen making LASIK flapsfor at least a decade. Upuntil now, practitionershave heard a lot about fem-

tosecond lasers in ophthalmology,but not nearly as much about the WaveLight FS200 Femtosecond Laser(Alcon, Fort Worth, Texas).

Does it deliver in terms of flap-making performance? How will itsupport eye health in eyes that un-dergo the LASIK procedure? Whatsets it apart from the competition?

Ronald Krueger, M.D., medicaldirector, department of refractivesurgery, Cole Eye Institute, and pro-fessor of ophthalmology, ClevelandClinic Lerner College of Medicine ofCase Western Reserve University,Cleveland, Ohio, is an excited userof the FS200 technology.

“It’s a newer femtosecond laserthat has a fast pulse repetition rateof 200 kHz,” Dr. Krueger said. Suchspeed provides standard flap cre-ation in about 6 seconds, accordingto Alcon.

Dr. Krueger said that the impactof this laser on the biomechanical

properties of the cornea is consider-ably improved compared to otherfemtosecond lasers in the market-place. For one, he is eager to use thesystem more because of its advancedsuction mechanism that reduces IOPincreases during LASIK.

“It has two suctions instead ofone,” Dr. Krueger said. “The first oneis able to give an adequate fixationon the eye. The second one is to ap-planate the cornea, and it sucks intothe ring already fixated on the eye.”

The geometry of the ring is suchthat it has a special spacer (distancepieces), which deforms the scleraless than a standard suction ringwith the IntraLase (Abbott MedicalOptics, Santa Ana, Calif.), Dr.Krueger said. The result is that IOPdoesn’t have to rise as high with theFS200, improving patient safety.

“The IOP rise with the FS200, inmy opinion, is lower compared tothe IntraLase,” Dr. Krueger said.“Surgeons would like to avoid exces-sive IOP rise. We don’t want to havetoo much stress on the eye. Patientscan have glaucoma, in which caseyou can do LASIK but you don’twant to have too much stress.”

Consistent suction is applied viaautomated vacuum control of thepatient interface, while ocular dis-tortion is minimized, according toAlcon.

Bubbles created by the femtosec-ond pulses are released in a less con-cerning manner with the FS200laser. With the IntraLase, Dr. Kruegersaid, laser pulses can yield bubblesthat become sequestered in thecornea. Instead of being released,the bubbles can form an opaquebubble layer (OBL), he said.

With the FS200, there is a venti-lation path that allows the bubblesto escape more efficiently. This is de-signed to minimize the formation ofOBL by evacuating the gas from theeye.

The beam control check featureis a nice add-on to the FS200 laser.“Femtosecond pulses are focusedbased on a presumed thickness andorientation of the applanationplate,” Dr. Krueger said. “It’s nice tohave a way of checking the distancefrom the optics to the edge of theflat plate, which assures precise flapthickness.”

This check is performed within4 seconds of treatment. “Before youoperate, within 4 seconds it does thecheck, you know what the thicknessis verified to be, this is calibrated,and it provides a more predictablethickness,” Dr. Krueger said.

Dr. Krueger said femtosecondlasers continue to be a step abovemicrokeratomes. “They provide uni-form thickness flaps that don’t go

EW San Diego 20116

Better biomechanics for all-laserLASIK vs. traditional LASIK

“The FS200 isfaster, has twosuction pumps

for less manipulation

getting things linedup with the

interface, affordsless IOP rise, yields

better flap predictability because of thebeam control

check, and resultsin less OBL”

Ronald Krueger, M.D.

Suction ring with distance pieces

Monday, March 28, 2011

excessively deep,” Dr. Krueger said.“They also produce better resultsthan microkeratome procedures.”

The FS200 laser couples with theWaveLight Eye-Q Excimer Laser,which together form the WaveLightRefractive Suite (Alcon). Advantagesof the Eye-Q Excimer Laser are thatit reduces the potential for stromal

dehydration of the cornea, flapshrinkage, sensitivity to eye move-ments, and patient fixation fatigue,according to Alcon.

“The system is manufacturedwell to come up with reproducibleresults,” Dr. Krueger said. “There’s aninterface between the two lasers thathelps guide surgery.”

In the future, even more inno-vative software may be released thatfurthers the advantages of using thetwo lasers together, Dr. Krueger said.

Overall, Dr. Krueger looks for-ward to using the FS200 Femtosec-ond Laser in more cases.

“It is faster, has two suctionpumps for less manipulation getting

EW San Diego 2011 7Capitalize on advanced technology for today's surgeon

continued from page 5

things lined up with the interface,affords less IOP rise, yields betterflap predictability because of thebeam control check, and results inless OBL,” Dr. Krueger said.

Contact informationKrueger: Krueger@ccf.org

nings. “The first femtosecond laserswere of large size, plagued with tech-nical limitations, sensitive to envi-ronmental conditions, and notreliable enough for clinical use,” ac-cording to a report by MichaelMrochen, Ph.D., IROC AG, Zurich,Switzerland, and colleagues. “In re-cent years, this situation hasmarkedly improved. Contemporaryfemtosecond lasers used in industryand in ophthalmic application pro-vide a high degree of stability andreliability.”

The study, published in Novem-ber 2010 in the Journal of RefractiveSurgery, investigated the feasibilityand technical features of the FS200 inrefractive and corneal laser surgery.

It analyzed 30 porcine eyesupon which the FS200 was used tocut an intended flap thickness of130 microns and a flap diameter of10.0 mm. The flap was precisely cut.The mean actual thickness was 128.7+/–7.8 microns and the mean flapdiameter was 10.0 +/–0.4 mm.

“The flap thickness measure-ments with the WaveLight FS200demonstrate a higher predictability

of the flap dimensions when com-pared to mechanical microker-atomes and a comparablepredictability to other femtosecondlasers,” Dr. Mrochen wrote.

There are some special charac-teristics of the FS200 that shouldhelp it to achieve excellent perform-ance, some of which were men-tioned in the study.

One is the laser’s ability to self-check parameters that affect thelaser beam’s performance. “To avoidpossible misalignments, the systemhas integrated energy and beamquality control through manifoldmeasurements and sensors at differ-ent points in the beam path,” Dr.Mrochen noted. “This assures a highquality spot and beam profile alongthe optical pathway.”

This beam control check is per-formed for each patient. “The lasersystem can compensate up to 300microns of z-positioning caused bytolerances and variations in theroom temperature,” Dr. Mrochen re-ported. “Such a beam control checkcan be performed before each treat-ment, and enables a distance setting

of the laser optics to every newplane applanation glass.”

Dr. Mrochen also suggested theFS200 is tailored to prevent anopaque bubble layer (OBL) fromforming, which can be a vexingissue for femtosecond lasers.

“Shooting a large number of laserpulses within a small region of thecornea can cause a disturbing layer ofmetastable gas bubbles,” Dr. Mrochenreported. “Whereas the cavitationbubbles that are directly created dur-ing the plasma expansion typicallycollapse after several microseconds,the observed metastable gas bubbleshave a lifetime of up to several min-utes or even hours. It is thus criticalto minimize or, better yet, even avoidthe formation of an opaque bubblelayer that might occur during thefemtosecond laser cutting.”

This is no small issue. Dr.Mrochen referenced an article byKaiserman et al, which reported that84 of 149 (56.4%) consecutive eyestreated with the IntraLase (AbbottMedical Optics, Santa Ana, Calif.)developed OBL.

With the FS200, optimized scan-ning algorithms allow OBL creationto be minimized, Dr. Mrochen said.

In the study, the FS200 createdan externalizing channel peripheralto the hinge of the corneal flap whileoptimizing the spatial and temporalscanning algorithm to allow gas todiffuse outside of the cornea.

“This is an encouraging resultand demonstrates that patient dis-comfort or even complications asso-ciated with opaque bubble layer canbe avoided,” reported Dr. Mrochen.

Given the solid research behindthe FS200, Dr. Slade’s positive feed-back about it in practice, and theFS200’s ability to seamlessly inte-grate with the WaveLight Eye-Q Excimer Laser, ophthalmologistsshould expect to hear more fromtheir fellow surgeons about this newfemtosecond laser.

ReferenceJournal of Refractive Surgery, vol. 26, Nov. 10,2010, S833-S838.

Contact informationSlade: sgs@visiontexas.com

Beam control calibration check Opaque bubble layer vent

8 EW San Diego 20118

“I choose to useAcrySof lenses

because they havedelivered excellentresults. The lens

fulfills the demands of

my patients”

Richard Packard, M.D.

First AcrySof patient celebrates20 years of improved vision

December 14, 2010 markedthe 20th anniversary ofthe first operation usingthe AcrySof lens implant(Alcon, Fort Worth,

Texas). Up until her treat-

ment at the age of 73,Nellie Diaper had de-pended on glasses formost of her life, but wasable to see without theaid of spectacles after heroperation. Ms. Diaper,now 93, still has excel-lent vision and can readwithout glasses.

Ms. Diaper returnedto King Edward VII Hos-pital in Windsor, U.K.,on the 20th anniversaryof her surgery to be re-united with her eye sur-geon, Richard Packard,M.D., senior surgeon,Prince Charles Eye Unit,Windsor, and directorand consultant oph-thalmic surgeon, ArnottEye Associates, London,and to mark the historicmilestone in the treat-ment of cataracts.

“At the time I hadno idea it was going tobe momentous,” Dr.Packard said. “The mate-rial was unlike anythingI’d used before. I wasused to working with sili-cone rubber and rigidplastic implants incataract surgery. Thisnew material felt stickyand was initially awk-ward to handle. The lens implanted in Ms. Diaper’s eye was monofo-cal and the surgery wasroutine. At the time,none of us thought of itas being revolutionary—it was just the start of aclinical trial.”

Dr. Packard has im-planted AcrySof lenses inmore than 8,000 cataractpatients over the past 20years. “I choose to useAcrySof lenses becausethey have delivered ex-cellent results. The lens

fulfills the demands of my patients,whether they want spectacle inde-pendence, enhanced distance, ornear vision. The lens can be insertedthrough an incision of about 2 mm,is stable, reliable, and has a low levelof secondary intervention,” he said.

Since the introduction of theAcrySof IOL, over 50 million AcrySoflenses have been implanted.

Contact informationPackard: eyequack@vossnet.co.uk

Monday, March 28, 2011

Ms. Diaper reunited with her eye surgeon, Dr. Packard

Dr. Packard, Ms. Diaper, and Ian Makepeace, sales and marketing manager, AlconSurgical U.K.

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