- Email: [email protected]
Second-wave hydrodissection for aspiration of cortical remains after femtosecond laser–assisted cataract surgery
1
TECHNIQUE
Second-wave hydrodissection for aspiration of cortical remains after femtosecond laser–assisted cataract surgery Jonathan C. Lake, MD, PhD, Celso Boianovsky, MD, Thiago de Faria Pacini, MD, Armando Crema, MD, PhD
We describe the technique of second-wave hydrodissection (the first wave being the initial cortical cleaving hydrodissection) performed after the removal of the cataract nucleus in femtosecond laser–assisted cataract surgery. After femtosecond laser application, the cortex is typically found adhered to the anterior capsule. Under high magnification, a steady stream of a balanced salt solution is directed toward the anterior capsule using a hydrodissection cannula. Full cleavage of the remaining cortex is observed by noting
F
emtosecond laser–assisted cataract surgery has emerged as a technological innovation for cataract surgery pretreatment that allows for greater precision in corneal incisions, capsulotomy, and nuclear fragmentation.1–3 Laser patterns can be used to configure these applications based on the surgeon’s preferences and patient’s clinical situation. Ocular tissue that has been treated with a femtosecond laser undergoes structural changes. These changes demand surgical approaches that are different from the steps performed in standard phacoemulsification. Regarding the capsulotomy, circular patterns of femtosecond laser irradiation are applied according to a preconfigured size and centration. However, the laser is applied in a range above and below the anterior capsule in the lines and spots inherent to the femtosecond laser.3 The vertical application of the femtosecond laser in the cortex below the anterior capsule leads to a structural change distinguished by white coloration that can be observed under the operating microscope (Figure 1). This change in turn tends to make corticalcleaving hydrodissection more difficult because a thin layer of cortex remains adhered to the capsule. This remaining layer of cortex also has the potential to render irrigation/ aspiration (I/A) of the cortex more difficult.4 We propose a technique that allows for liberation of this thin layer of adhered cortex after aspiration of the nucleus.
the appearance of a dark inner circle by the capsulotomy edge once the balanced salt solution wave has separated the cortex from the capsule. Irrigation/aspiration (I/A) of the cortical remains after the second wave is faster than I/A without this step in femtosecond laser–assisted cataract surgery. J Cataract Refract Surg 2018; -:-–- Q 2018 ASCRS and ESCRS Online Video
SURGICAL TECHNIQUE Cortical-cleaving hydrodissection is one of the first steps performed after capsulorhexis. This first wave of balanced salt solution is supposed to separate the cortex from the capsule. However, in femtosecond laser–assisted cataract surgery, this does not always occur. Figure 1 shows the typical appearance of cortical remains after nucleus removal in femtosecond laser–assisted cataract surgery. The white aspect of the cortex is a result of the vertical application of the laser to the cortex. This leads to a very thin layer of cortex underlining the anterior capsule, similar to a thin epinucleus. The second wave is performed similar to conventional hydrodissection using any hydrodissection cannula. However, trying to obtain physical separation of the cortex from the capsule with the cannula should be avoided. Under high magnification, a steady stream of a balanced salt solution is aimed toward the capsule–cortex layer, preferably opposite the point of entry of the cannula. This is to allow for the stream to search for an opening that would permit a second hydrodissection. Once the balanced salt solution has found this opening, a distinct wave should be observed, indicating full cleavage of the cortex from the entire capsular bag. Complete release of the cortical layer is evidenced by a dark inner circle that is formed by the released cortex
Submitted: January 9, 2018 | Final revision submitted: February 28, 2018 | Accepted: March 7, 2018 gico (de Faria Pacini), Brasilia, and the Walsh & Crema From the Department of Cataract (Lake, Boianovsky), Brasilia Vision Hospital, and the Pacini Hospital Oftalmolo Clinica e Microcirurgia Ocular (Crema), Rio de Janeiro, Brazil. Film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, California, USA, May 2017. Corresponding author: Jonathan C. Lake, MD, PhD, Brasilia Vision Hospital, SHIGS 714/914, room 101, Brasilia, DF, Brazil. Email: [email protected]. Q 2018 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2018.03.031
2
TECHNIQUE: SECOND-WAVE HYDRODISSECTION OF CORTICAL REMAINS
Figure 1. Cortical remains close to the border of the femtosecond laser capsulotomy. The white (arrow) indicates laser-induced structural change.
Figure 2. Inner circle (arrow) indicates complete release of cortical remains.
pressing against the round capsulotomy (Figure 2). Further attempts at other positions within the capsular bag can be made if there is not a full release. This can be followed by conventional I/A with any preferred device or technique. The released cortex can be fully aspirated from the center of the eye without manipulation of the capsular bag (Figure 3) (Video 1, available at http://jcrs journal.org). The video recordings of 56 patients who had femtosecond laser–assisted cataract surgery were retrospectively reviewed. Of these patients, 28 had successful secondwave hydrodissection followed by I/A and 28 had I/A without the second wave. The difference in the time code was registered from the moment of entry of the I/A device until aspiration of the last cortical remains. Table 1 shows the I/A times with and without the second wave. Both samples were normal according to the Shapiro-Wilk test. A comparison of the means using the Student t test showed that I/A with the second wave was significantly faster than I/A without the second wave (P ! .001). All tests were performed using SPSS for Mac software (version 23, IBM Corp.).
techniques have been described for I/A optimization.4,5,7–9 Since its introduction by Fine in 1992,8 cortical-cleaving hydrodissection has been a crucial step in the I/A process. Successful cleaving can allow for more successful surgery with fewer complications.4 Removal of cortical remains by irrigation alone has also been described by Dewey.7 Second-wave hydrodissection builds on previous techniques to address the unique situation presented by cortical remains as a result of femtosecond laser–assisted cataract surgery. Because second-wave hydrodissection is performed after removal of the cataract nucleus, the wave and complete release of the cortex can be easily observed because of the intense red reflex present during this part of the procedure. Complete release of the cortex might depend on the quantity of cortex adhered to the capsule. As such, it is possible that incomplete second-wave hydrodissection will occur if different portions of the cortical remains have been released. The inner circle sign indicates complete release of the cortical remains. Irrigation/aspiration after the second wave in femtosecond laser–assisted cataract surgery is significantly faster than without the second wave. However, we believe that even incomplete release of the cortex with irrigation might further improve the I/A procedure with coaxial or bimanual devices. Femtosecond laser–assisted cataract surgery, although controversial, was developed to improve surgical and clinical outcomes; however, despite some similarities, the surgical steps differ considerably from those associated with conventional phacoemulsification. We believe that second-wave hydrodissection can help improve I/A
DISCUSSION Irrigation/aspiration of cortical remains a critical step during cataract surgery.4,5 It is also a step that may present complications, even for experienced surgeons.6 Several
Table 1. Irrigation/aspiration technique.
times
according
to
Irrigation/Aspiration Time (Seconds) Parameter
Figure 3. Central aspiration of released cortex. Volume - Issue - - 2018
Mean Median SD Min Max
With 2nd Wave
Without 2nd Wave
39.04 35.5 16.27 12 79
68.61 66.5 18.68 37 109
3
TECHNIQUE: SECOND-WAVE HYDRODISSECTION OF CORTICAL REMAINS
maneuvers during femtosecond laser–assisted cataract surgery. WHAT WAS KNOWN Aspiration of cortical remains is more difficult in femtosecond laser–assisted cataract surgery as a result of cortical adhesion to the capsular bag.
WHAT THIS PAPER ADDS Second-wave hydrodissection is a new technique that might be useful for the aspiration of cortical remains after removal of the cataract nucleus in femtosecond laser–assisted cataract surgery.
REFERENCES 1. Chen X, Xiao W, Ye S, Chen W, Liu Y. Efficacy and safety of femtosecond laser-assisted cataract surgery versus conventional phacoemulsification for cataract: A meta-analysis of randomized controlled trials. Sci Rep 2015; 5:13123. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542 520/pdf/srep13123.pdf. Accessed April 10, 2018 2. Conrad-Hengerer I, Al Juburi M, Schultz T, Hengerer FH, Dick HB. Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser–assisted cataract surgery: three-month follow-up. J Cataract Refract Surg 2013; 39:1307–1313 3. He L, Sheehy K, Culbertson W. Femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol 2011; 22:43–52. Available at: http://bladele sscataractindia.com/downloads/He-Curr-Opin-Ophthalmol-Jan-2011.pdf. Accessed April 10, 2018
4. Peng Q, Apple DJ, Visessook N, Werner L, Pandey SK, Escobar-Gomez M, Schoderbek R, Guindi A. Surgical prevention of posterior capsule opacification. Part 2: enhancement of cortical cleanup by focusing on hydrodissection. J Cataract Refract Surg 2000; 26:188–197 5. Brauweiler P. Bimanual irrigation/aspiration. J Cataract Refract Surg 1996; 22:1013–1016 6. Ti S-E, Yang Y-N, Lang SS, Chee SP. A 5-year audit of cataract surgery outcomes after posterior capsule rupture and risk factors affecting visual acuity. Am J Ophthalmol 2014; 157:180–185 7. Dewey SH. Cortical removal simplified by J-cannula irrigation. J Cataract Refract Surg 2002; 28:11–14 8. Fine IH. Cortical cleaving hydrodissection. J Cataract Refract Surg 1992; 18:508–512 9. Nakano CT, Pimenta Motta AF, Hida WT, Nakamura CM, Tzelikis PF, Ruiz Alves M, Werner L. Hurricane cortical aspiration technique: one-step continuous circular aspiration maneuver. J Cataract Refract Surg 2014; 40:514– 516. Available at: http://www.jcrsjournal.org/article/S0886-3350(14)00007 -8/pdf. Accessed April 10, 2018
Disclosures: Dr. Crema is a consultant to Alcon Laboratories, Inc. None of the other authors has a financial or proprietary interest in any material or method mentioned.
First author: Jonathan C. Lake, MD, PhD Department of Cataract, Brasilia Vision Hospital, Brasilia, Brazil
Video 1. Second wave followed by the inner circle sign and irrigation/aspiration of the released cortex.
Volume - Issue - - 2018
TECHNIQUE
Second-wave hydrodissection for aspiration of cortical remains after femtosecond laser–assisted cataract surgery Jonathan C. Lake, MD, PhD, Celso Boianovsky, MD, Thiago de Faria Pacini, MD, Armando Crema, MD, PhD
We describe the technique of second-wave hydrodissection (the first wave being the initial cortical cleaving hydrodissection) performed after the removal of the cataract nucleus in femtosecond laser–assisted cataract surgery. After femtosecond laser application, the cortex is typically found adhered to the anterior capsule. Under high magnification, a steady stream of a balanced salt solution is directed toward the anterior capsule using a hydrodissection cannula. Full cleavage of the remaining cortex is observed by noting
F
emtosecond laser–assisted cataract surgery has emerged as a technological innovation for cataract surgery pretreatment that allows for greater precision in corneal incisions, capsulotomy, and nuclear fragmentation.1–3 Laser patterns can be used to configure these applications based on the surgeon’s preferences and patient’s clinical situation. Ocular tissue that has been treated with a femtosecond laser undergoes structural changes. These changes demand surgical approaches that are different from the steps performed in standard phacoemulsification. Regarding the capsulotomy, circular patterns of femtosecond laser irradiation are applied according to a preconfigured size and centration. However, the laser is applied in a range above and below the anterior capsule in the lines and spots inherent to the femtosecond laser.3 The vertical application of the femtosecond laser in the cortex below the anterior capsule leads to a structural change distinguished by white coloration that can be observed under the operating microscope (Figure 1). This change in turn tends to make corticalcleaving hydrodissection more difficult because a thin layer of cortex remains adhered to the capsule. This remaining layer of cortex also has the potential to render irrigation/ aspiration (I/A) of the cortex more difficult.4 We propose a technique that allows for liberation of this thin layer of adhered cortex after aspiration of the nucleus.
the appearance of a dark inner circle by the capsulotomy edge once the balanced salt solution wave has separated the cortex from the capsule. Irrigation/aspiration (I/A) of the cortical remains after the second wave is faster than I/A without this step in femtosecond laser–assisted cataract surgery. J Cataract Refract Surg 2018; -:-–- Q 2018 ASCRS and ESCRS Online Video
SURGICAL TECHNIQUE Cortical-cleaving hydrodissection is one of the first steps performed after capsulorhexis. This first wave of balanced salt solution is supposed to separate the cortex from the capsule. However, in femtosecond laser–assisted cataract surgery, this does not always occur. Figure 1 shows the typical appearance of cortical remains after nucleus removal in femtosecond laser–assisted cataract surgery. The white aspect of the cortex is a result of the vertical application of the laser to the cortex. This leads to a very thin layer of cortex underlining the anterior capsule, similar to a thin epinucleus. The second wave is performed similar to conventional hydrodissection using any hydrodissection cannula. However, trying to obtain physical separation of the cortex from the capsule with the cannula should be avoided. Under high magnification, a steady stream of a balanced salt solution is aimed toward the capsule–cortex layer, preferably opposite the point of entry of the cannula. This is to allow for the stream to search for an opening that would permit a second hydrodissection. Once the balanced salt solution has found this opening, a distinct wave should be observed, indicating full cleavage of the cortex from the entire capsular bag. Complete release of the cortical layer is evidenced by a dark inner circle that is formed by the released cortex
Submitted: January 9, 2018 | Final revision submitted: February 28, 2018 | Accepted: March 7, 2018 gico (de Faria Pacini), Brasilia, and the Walsh & Crema From the Department of Cataract (Lake, Boianovsky), Brasilia Vision Hospital, and the Pacini Hospital Oftalmolo Clinica e Microcirurgia Ocular (Crema), Rio de Janeiro, Brazil. Film presented at the ASCRS Symposium on Cataract, IOL and Refractive Surgery, Los Angeles, California, USA, May 2017. Corresponding author: Jonathan C. Lake, MD, PhD, Brasilia Vision Hospital, SHIGS 714/914, room 101, Brasilia, DF, Brazil. Email: [email protected]. Q 2018 ASCRS and ESCRS Published by Elsevier Inc.
0886-3350/$ - see frontmatter https://doi.org/10.1016/j.jcrs.2018.03.031
2
TECHNIQUE: SECOND-WAVE HYDRODISSECTION OF CORTICAL REMAINS
Figure 1. Cortical remains close to the border of the femtosecond laser capsulotomy. The white (arrow) indicates laser-induced structural change.
Figure 2. Inner circle (arrow) indicates complete release of cortical remains.
pressing against the round capsulotomy (Figure 2). Further attempts at other positions within the capsular bag can be made if there is not a full release. This can be followed by conventional I/A with any preferred device or technique. The released cortex can be fully aspirated from the center of the eye without manipulation of the capsular bag (Figure 3) (Video 1, available at http://jcrs journal.org). The video recordings of 56 patients who had femtosecond laser–assisted cataract surgery were retrospectively reviewed. Of these patients, 28 had successful secondwave hydrodissection followed by I/A and 28 had I/A without the second wave. The difference in the time code was registered from the moment of entry of the I/A device until aspiration of the last cortical remains. Table 1 shows the I/A times with and without the second wave. Both samples were normal according to the Shapiro-Wilk test. A comparison of the means using the Student t test showed that I/A with the second wave was significantly faster than I/A without the second wave (P ! .001). All tests were performed using SPSS for Mac software (version 23, IBM Corp.).
techniques have been described for I/A optimization.4,5,7–9 Since its introduction by Fine in 1992,8 cortical-cleaving hydrodissection has been a crucial step in the I/A process. Successful cleaving can allow for more successful surgery with fewer complications.4 Removal of cortical remains by irrigation alone has also been described by Dewey.7 Second-wave hydrodissection builds on previous techniques to address the unique situation presented by cortical remains as a result of femtosecond laser–assisted cataract surgery. Because second-wave hydrodissection is performed after removal of the cataract nucleus, the wave and complete release of the cortex can be easily observed because of the intense red reflex present during this part of the procedure. Complete release of the cortex might depend on the quantity of cortex adhered to the capsule. As such, it is possible that incomplete second-wave hydrodissection will occur if different portions of the cortical remains have been released. The inner circle sign indicates complete release of the cortical remains. Irrigation/aspiration after the second wave in femtosecond laser–assisted cataract surgery is significantly faster than without the second wave. However, we believe that even incomplete release of the cortex with irrigation might further improve the I/A procedure with coaxial or bimanual devices. Femtosecond laser–assisted cataract surgery, although controversial, was developed to improve surgical and clinical outcomes; however, despite some similarities, the surgical steps differ considerably from those associated with conventional phacoemulsification. We believe that second-wave hydrodissection can help improve I/A
DISCUSSION Irrigation/aspiration of cortical remains a critical step during cataract surgery.4,5 It is also a step that may present complications, even for experienced surgeons.6 Several
Table 1. Irrigation/aspiration technique.
times
according
to
Irrigation/Aspiration Time (Seconds) Parameter
Figure 3. Central aspiration of released cortex. Volume - Issue - - 2018
Mean Median SD Min Max
With 2nd Wave
Without 2nd Wave
39.04 35.5 16.27 12 79
68.61 66.5 18.68 37 109
3
TECHNIQUE: SECOND-WAVE HYDRODISSECTION OF CORTICAL REMAINS
maneuvers during femtosecond laser–assisted cataract surgery. WHAT WAS KNOWN Aspiration of cortical remains is more difficult in femtosecond laser–assisted cataract surgery as a result of cortical adhesion to the capsular bag.
WHAT THIS PAPER ADDS Second-wave hydrodissection is a new technique that might be useful for the aspiration of cortical remains after removal of the cataract nucleus in femtosecond laser–assisted cataract surgery.
REFERENCES 1. Chen X, Xiao W, Ye S, Chen W, Liu Y. Efficacy and safety of femtosecond laser-assisted cataract surgery versus conventional phacoemulsification for cataract: A meta-analysis of randomized controlled trials. Sci Rep 2015; 5:13123. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4542 520/pdf/srep13123.pdf. Accessed April 10, 2018 2. Conrad-Hengerer I, Al Juburi M, Schultz T, Hengerer FH, Dick HB. Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser–assisted cataract surgery: three-month follow-up. J Cataract Refract Surg 2013; 39:1307–1313 3. He L, Sheehy K, Culbertson W. Femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol 2011; 22:43–52. Available at: http://bladele sscataractindia.com/downloads/He-Curr-Opin-Ophthalmol-Jan-2011.pdf. Accessed April 10, 2018
4. Peng Q, Apple DJ, Visessook N, Werner L, Pandey SK, Escobar-Gomez M, Schoderbek R, Guindi A. Surgical prevention of posterior capsule opacification. Part 2: enhancement of cortical cleanup by focusing on hydrodissection. J Cataract Refract Surg 2000; 26:188–197 5. Brauweiler P. Bimanual irrigation/aspiration. J Cataract Refract Surg 1996; 22:1013–1016 6. Ti S-E, Yang Y-N, Lang SS, Chee SP. A 5-year audit of cataract surgery outcomes after posterior capsule rupture and risk factors affecting visual acuity. Am J Ophthalmol 2014; 157:180–185 7. Dewey SH. Cortical removal simplified by J-cannula irrigation. J Cataract Refract Surg 2002; 28:11–14 8. Fine IH. Cortical cleaving hydrodissection. J Cataract Refract Surg 1992; 18:508–512 9. Nakano CT, Pimenta Motta AF, Hida WT, Nakamura CM, Tzelikis PF, Ruiz Alves M, Werner L. Hurricane cortical aspiration technique: one-step continuous circular aspiration maneuver. J Cataract Refract Surg 2014; 40:514– 516. Available at: http://www.jcrsjournal.org/article/S0886-3350(14)00007 -8/pdf. Accessed April 10, 2018
Disclosures: Dr. Crema is a consultant to Alcon Laboratories, Inc. None of the other authors has a financial or proprietary interest in any material or method mentioned.
First author: Jonathan C. Lake, MD, PhD Department of Cataract, Brasilia Vision Hospital, Brasilia, Brazil
Video 1. Second wave followed by the inner circle sign and irrigation/aspiration of the released cortex.
Volume - Issue - - 2018