Femtosecond laser cataract surgery

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The femtosecond laser cataract operation is an ophthalmological , surgical procedure for the laser-assisted operation of cataracts . The designation of this intervention is not standardized. There are also acronyms such as ReLACS (refractive laser-assisted cataract surgery ), FLACS ( femtosecond laser-assisted cataract surgery ) and FALCS ( femtosecond-assisted laser cataract surgery ). The femtosecond laser technology was originally used in the field of refractive surgery ( LASIK ) since 2001 , but was then further developed into a high-precision instrument for cataract surgery.

Cataract surgery is the most common surgical intervention worldwide with around 19 million operations annually. The World Health Organization ( WHO ) estimates that the number will increase to 32 million by 2020. The reason for this is the assumption that the population of over 65-year-olds will double between 2000 and 2020. The use of the femtosecond laser offers the possibility of a more precise implementation of the cataract operation while at the same time reducing operational risks.

Provided that a significant reduction in costs and an increase in the quality of results are achieved in the future, the new process is said to have considerable economic development potential and competitiveness within medical care, including for those with statutory health insurance.

Femtosecond laser cataract surgery methodology

A femtosecond laser works with infrared light pulses in the range of femtoseconds ( quadrillionths of a second , 1 fs = 10 −15  s = 0,000,000,000,000.001 s). Strong focus (small point of light) creates high intensities in the focus point. If the pulse duration is short, small amounts of energy are used per pulse. This separates the tissue at the atomic level by converting laser energy into mechanical energy (photodisruption). Very short interaction times prevent thermal damage and the tissue is protected.

Due to the high energy density, thousands of air bubbles are formed from water and carbon dioxide, which separate the tissue at precisely calculated points, usually without any injury or other tissue damage.

A 3D imaging procedure supports the femtosecond laser-assisted procedure. By means of optical coherence tomography (OCT), an imaging ultrasonic similar images, structures of the eye such as the lens and the cornea in the micrometer range imaged. On this basis, the action of the laser can be precisely displayed and guided.

The entire intervention takes place in two sections that are also spatially separated from one another. After the patient has been placed under the laser device in a separate treatment room, the laser performs the first and most important surgical steps:

  • computer-controlled, step-shaped cut through the cornea as access to the eye,
  • computer-controlled opening of the lens capsule,
  • Fragmentation of the clouded lens.

In the next section of the operation, the further steps take place in a sterile operating room. First, the accesses to the eye are opened completely with a blunt instrument. The surgeon also continues to manually suction the divided lens and insert the artificial lens .

Advantages of the surgical method

Compared to the manual cataract operation , which has been established for more than 40 years , the femtosecond laser-assisted operation method represents a further development. The operation can be carried out more gently and with fewer complications. This promotes wound healing. Modifications to the laser parameters allow the operation to be customized.

A more precise, circular opening of the lens capsule is achieved by means of the femtosecond laser, which is relevant for central lens positioning. A tearing of the capsule with the risk of the artificial lens slipping off is to be reduced. Furthermore, eyes treated in this way show lower aberrations . A more precise opening of the lens capsule offers better conditions, especially for the use of premium artificial lenses.

A self-closing incision profile in the cornea promotes faster wound healing on the one hand, and counteracts the risk of a renewed curvature of the cornea caused by the surgeon on the other.

The use of the femtosecond laser enables significantly better prognosis, reproducibility and accuracy of the surgical result in terms of glasses independence .

The reduction of the required ultrasound energy compared to the standard cataract operation leads to a protection of the surrounding tissue, in particular to less stress on the corneal endothelium, and consequently to fewer complications after the operation. A reduction in the energy required by around 50% is described in the literature.

During the procedure, there is also the option of correcting astigmatism by means of superficial laser cuts in the cornea (anti-astigmatic relief cuts). This also enables a postoperative improvement in the raw visual acuity ( visual acuity without glasses or contact lens correction ).

The femtosecond laser-assisted technique can reduce the risk of surgery in eyes with other concomitant diseases such as pseudoexfoliation syndrome or corneal dystrophies .

Disadvantages and risks of use

Even with new procedures, the result of the operation depends on the surgeon's experience, i.e. on the number of operations he has already performed. For special patient groups, femtosecond laser-assisted cataract surgery is only suitable with restrictions, and possibly not at all.

In patients with insufficient expandable pupil mechanical spreader for laser treatment, called Irisretraktoren must be placed in the eye. This additional measure increases the operational risk.

Relatively clear optical conditions are a prerequisite for the successful use of the laser. Pronounced scarring on the cornea, for example, make it difficult or impossible to use.

Parkinson's patients may have to undergo surgery under general anesthesia . Equally aggravating for a femtosecond laser-assisted cataract surgery are pronounced diseases of the spine , which lead to stiffening and thus difficult positioning of the patient under the laser.

In addition, the operation time is extended by the two treatment steps in different rooms.

The costs incurred for the patient are significantly higher than with conventional interventions. On the one hand, this is due to the operational effort and, on the other hand, the high costs of purchasing and maintaining the laser and consumables. Since this surgical technique has not yet been included in the fee schedule, patients with statutory health insurance must expect considerable financial burdens until a corresponding regulation is reached. Private health insurance companies currently reimburse these additional costs in very different ways.

technology

The first clinical application of a femtosecond laser in cataract surgery was performed by Zoltán Zsolt Nagy in Budapest , Hungary in 2008. This was followed by Harvey Uy in Asia in 2009 and Steven Slade in the USA in 2010, as well as Michael Lawless in Australia in 2011. In Germany, Burkhard Dick is one of the first ophthalmic surgeons to use the femtosecond laser in cataract surgery.

Six different femtosecond laser systems are currently approved on the market. The various systems may differ. a. in the suction process, imaging, software, energy used, treatment patterns and mobility. For example, the interface - the connecting piece between the laser and the surface of the patient's eye, which is relatively rigid in many systems - is filled with liquid in some systems so that the surface curvature of the eye does not change upon contact.

Sources and literature

  • Burkhard Dick, Ronald D. Gerste, Tim Schultz: Femtosecond Laser in Ophthalmology. Thieme, New York 2018, ISBN 9781626232365 .
  • C. Wiemer, M. Galanski, J. Hänsgen, P. Kaulen: One year of experience with femtosecond laser-assisted cataract surgery . In: Clinical Monthly Ophthalmology. 230, 2013, KV27, doi: 10.1055 / s-0033-1363382 .

Web links

Individual evidence

  1. ↑ a b Kendall E. Donaldson et al: Femtosecond laser-assisted cataract surgery . In: Journal of Cataract & Refractive Surgery . tape 39 , no. November 11 , 2013, p. 1753–1763 , doi : 10.1016 / j.jcrs.2013.09.002 , PMID 24160384 ( PDF [accessed December 17, 2014]).
  2. ↑ a b c d Zoltan Nagy, Agnes Takacs, Tamas Filkorn, Melvin Sarayba: Initial Clinical Evaluation of an Intraocular Femtosecond Laser in Cataract Surgery . In: Journal of Refractive Surgery . tape 25 , no. December 12 , 2009, pp. 1053-1060 , doi : 10.3928 / 1081597X-20091117-04 .
  3. ^ I. Ratkay-Traub, T. Juhasz, C. Horvath, C. Suarez, K. Kiss, I. Ferincz, R. Kurtz: Ultra-short pulse (femtosecond) laser surgery: initial use in LASIK flap creation. In: Ophthalmology clinics of North America . tape 14 , no. 2 , June 2001, p. 347-55, viii-ix , PMID 11406430 .
  4. ↑ Peter Kim, Gerard L Sutton, David S Rootman: Applications of the femtosecond laser in corneal refractive surgery: . In: Current Opinion in Ophthalmology . tape 22 , no. 4 , July 2011, p. 238-244 , doi : 10.1097 / ICU.0b013e3283477c9c .
  5. ↑ S. Trikha, AMJ Turnbull, RJ Morris, DF Anderson, P. Hossain: The journey to femtosecond laser-assisted cataract surgery: new beginnings or a false dawn . In: Eye . tape 27 , no. 4 , April 2013, p. 461-473 , doi : 10.1038 / eye.2012.293 .
  6. ^ Garry Brian, Hugh Taylor: Cataract blindness: challenges for the 21st century . In: Bulletin of the World Health Organization . tape 79 , no. 3 , 2001, p. 249-256 , PMID 11285671 , PMC 2566371 (free full text).
  7. ↑ a b Robin G. Abell, Penelope L. Allen, Brendan J. Vote: Anterior chamber flare after femtosecond laser-assisted cataract surgery . In: Journal of Cataract & Refractive Surgery . tape 39 , no. 9 , September 2013, p. 1321-1326 , doi : 10.1016 / j.jcrs.2013.06.009 .
  8. ↑ Lecture at the 112th Congress of the German Ophthalmological Society (DOG) , September 2014. Rupert Menapace: New “gentle” therapy option for cataracts: How good is the femtosecond laser?
  9. ↑ a b c Leonardo Mastropasqua, Lisa Toto, Roberta Calienno, Peter A. Mattei, Alessandra Mastropasqua, Luca Vecchiarino, Donato Di Iorio: Scanning electron microscopy evaluation of capsulorhexis in femtosecond laser-assisted cataract surgery . In: Journal of Cataract & Refractive Surgery . tape 39 , no. 10 , October 2013, p. 1581-1586 , doi : 10.1016 / j.jcrs.2013.06.016 .
  10. ↑ a b c d e f g h Hana Abouzeid, Walter Ferrini: Femtosecond-laser assisted cataract surgery: a review . In: Acta Ophthalmologica . tape 92 , no. 7 , November 2014, p. 597-603 , doi : 10.1111 / aos.12416 .
  11. ↑ a b c d e H. B. Dick, T. Schultz: Femtosecond laser-assisted cataract surgery . In: The ophthalmologist . tape 111 , no. 7 , July 2014, p. 614-623 , doi : 10.1007 / s00347-014-3033-0 .
  12. ↑ GU Auffarth: Precision on the Eye - Use of Femtosecond Lasers in Cataract Surgery. In: Forum Sanitas - The informative medical magazine. No. 4, 2014, pp. 28-30.
  13. ↑ Daniel V. Palanker include: Femtosecond Laser-Assisted Cataract Surgery with Integrated Optical Coherence Tomography . In: Science Translational Medicine . tape 2 , no. 58 , November 17, 2010, p. 58ra85-58ra85 , doi : 10.1126 / scitranslmed . 3001305 , PMID 21084720 .
  14. ↑ a b c Kasu Prasad Reddy, Jochen Kandulla, Gerd U. Auffarth : Effectiveness and safety of femtosecond laser-assisted lens fragmentation and anterior capsulotomy versus the manual technique in cataract surgery . In: Journal of Cataract & Refractive Surgery . tape 39 , no. 9 , September 2013, p. 1297-1306 , doi : 10.1016 / j.jcrs.2013.05.035 .
  15. Jump up ↑ Friedman, NJ, Palanker, DV, Schuele, G., Andersen, D., Marcellino, G., Seibel, BS, ... & Culbertson, WW (2011). Femtosecond laser capsulotomy. Journal of Cataract & Refractive Surgery, 37 (7), 1189-1198.
  16. ↑ Kinga Kránitz, Agnes Takacs, Kata Miháltz, Illés Kovács, Michael C. Knorz, Zoltán Z. Nagy: Femtosecond Laser Capsulotomy and Manual Continuous Curvilinear Capsulorrhexis Parameters and Their Effects on Intraocular Lens Centration . In: Journal of Refractive Surgery . tape 27 , no. 8 , August 2011, p. 558-563 , doi : 10.3928 / 1081597X-20110623-03 .
  17. ↑ Kata Miháltz, Michael C. Knorz, Jorge L. Alió, Ágnes I. Takács, Kinga Kránitz, Illés Kovács, Zoltán Z. Nagy: Internal Aberrations and Optical Quality After Femtosecond Laser Anterior Capsulotomy in Cataract Surgery . In: Journal of Refractive Surgery . tape 27 , no. 10 , October 2011, p. 711-716 , doi : 10.3928 / 1081597X-20110913-01 .
  18. ↑ Timothy V. Roberts, Michael Lawless, Shveta J. Bali, Chris Hodge, Gerard Sutton: Surgical Outcomes and Safety of Femtosecond Laser Cataract Surgery: A Prospective Study of 1500 Consecutive Cases . In: Ophthalmology . tape 120 , no. 2 , February 2013, p. 227-233 , doi : 10.1016 / j.ophtha.2012.10.026 .
  19. ↑ Robin G. Abell, Nathan M. Kerr, Allister R. Howie, Mohd AA Mustaffa Kamal, Penelope L. Allen, Brendan J. Vote: Effect of femtosecond laser-assisted cataract surgery on the corneal endothelium . In: Journal of Cataract & Refractive Surgery . tape 40 , no. November 11 , 2014, p. 1777–1783 , doi : 10.1016 / j.jcrs.2014.05.031 .
  20. ^ Theresa Rückl, Alois K. Dexl, Alexander Bachernegg, Veronika Reischl, Wolfgang Riha, Josef Ruckhofer, Perry S. Binder, Günther Grabner: Femtosecond laser-assisted intrastromal arcuate keratotomy to reduce corneal astigmatism . In: Journal of Cataract & Refractive Surgery . tape 39 , no. 4 , April 2013, p. 528-538 , doi : 10.1016 / j.jcrs.2012.10.043 .
  21. ↑ G. Gerten: The first experiences are encouraging. Femtosecond laser-assisted cataract surgery for weak endothelium after DMEK, keratoplasty, corneae guttata. In: Ophthalmological News. No. 11, 2014, pp. 9-10.
  22. ^ Werner Bachmann, Ophthalmologic Cooperative Westphalia e. G .: Billing recommendation for cataract surgery using femtosecond laser ( memento of the original from March 4, 2016 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice.  @1@ 2Template: Webachiv / IABot / ag-westfalen.de
  23. ^ "The Future of Laser Cataract Surgery" Keynote Lecture American Academy of Ophthalmology, Subspecialty Day, Chicago, November 2012.
  24. ↑ Ronald D. Gerste: Cataract surgery with laser instead of scalpel. In: www.welt.de. September 24, 2012, accessed November 9, 2019 .
  25. ↑ Increased intraocular pressure and glaucoma in cataract surgery. University Eye Clinic Bochum, September 19, 2019, accessed on November 9, 2019 .