DOI: 10.5301/ejo.5000443
Eur J Ophthalmol 2014; 24 ( 4 ): 623-625
case report
Intraocular femtosecond laser use in traumatic cataract Zsuzsanna Szepessy, Ágnes Takács, Kinga Kránitz, Tamás Filkorn, Zoltán Z. Nagy Department of Ophthalmology, Semmelweis University, Budapest - Hungary
Purpose: To report the use of femtosecond laser cataract surgery in a traumatic case. Methods: A 38-year-old man had a penetrating eye injury while working with wire. The corneal laceration was sutured first. In the postoperative period, cortical cataract appeared in the crystalline lens; therefore, in the second session, cataract surgery was performed using a femtosecond laser system (Alcon-LenSx Lasers Inc.). Results: Corneal incisions, an intact 4.5 mm capsulorhexis, and nucleus liquefaction were performed with the femtosecond laser. Corrected distance visual acuity was 0.9 1 month after surgery. Conclusions: Femtosecond laser is an effective method in traumatic cataract cases after penetrating eye injury. Corneal incisions, capsulorhexis, and nucleus liquefaction can be performed precisely and safety. Keywords: Capsulorhexis, Cataract, Femtosecond laser, Trauma Accepted: January 26, 2014
INTRODUCTION Serious eye injuries (blunt trauma and penetrating eye injury) frequently involve the crystalline lens, leading to cataract formation. Associated complications like zonular weakness/rupture and disruption of the anterior/posterior lens capsule may complicate traumatic cataract extraction. With the application of an intraocular femtosecond laser, 3 crucial steps of cataract surgery can be replaced: positioned self-sealing corneal incisions, well-centered, intact circular anterior capsulotomy, and lens fragmentation/liquefaction (1). These steps are important in traumatic cases. Injuries of the anterior capsule make manual capsulotomy difficult; anterior tears may easily extend to the posterior capsule. Capsular complications during cataract extraction can complicate further steps of the surgery and decrease the probability of achieving good long- and short-term postoperative results. Previously published articles reported that reproducibility of capsulorhexis is significantly better with a femtosecond laser in nontraumatic cataracts; however, femtosecond laser has been used effectively during traumatic cataract extraction.
Reducing phacoemulsification energy with the application of a femtosecond laser is also a potential benefit during cataract extraction, reducing further trauma to the corneal endothelial cell layer vs manual phacoemulsification (2). This article presents the successful use of intraocular femtosecond laser in performing corneal incisions, round, intact capsulorhexis, and nucleus liquefaction in traumatic cataract.
Case report A 38-year-old upholsterer had a penetrating eye injury while working with wire, hitting his right eye with it. He removed the penetrating piece of wire from his eye. On admission, uncorrected distance visual acuity was 0.4. Slit-lamp examination showed 3-mm corneal laceration at 10 o’clock paracentrally with a prolapsing iris. The anterior chamber was shallow and the eye was hypotonic. The lens was clear, but after pupillary dilation a fold was found at 10 o’clock on the anterior capsule. By Scheimpflug imaging system (Oculus Pentacam HR 70900; Oculus Optikgeräete GmbH, Wetzlar, Germany), the anterior capsule
© 2014 Wichtig Publishing - ISSN 1120-6721
623
Femtosecond laser use in traumatic cataract
did not extend to the posterior capsule. A 3-piece acrylic intraocular lens (IOL) (+29.0 D-S AcrySof MA60AC, Alcon Laboratories Inc., Fort Worth, Texas, USA) was implanted into the capsular bag. Uncorrected distance visual acuity increased to 0.7 the first postoperative day. One month after surgery, corrected distance visual acuity was 0.9.
DISCUSSION
Fig. 1 - Scheimpflug image (A) and slit-lamp photograph (B) after primary care. (A) By Scheimpflug imaging system (Oculus Pentacam HR 70900; Oculus Optikgeräete GmbH, Wetzlar, Germany), the anterior capsule injury became visible (white arrow). (B) Corneal sutures in place after primary care.
injury became more visible (Fig. 1A). Orbital computed tomography demonstrated no intraocular foreign body. During primary care, the iris was repositioned and the corneal laceration was sutured with two 10-0 interrupted sutures (Fig. 1B). Postoperatively, the visual acuity of the patient decreased due to anterior cortical cataract formation. Two weeks after the primary care, cataract surgery was performed using an intraocular femtosecond laser (Alcon-LenSx Lasers Inc., Aliso Viejo, California, USA). Pupil size was 8 mm after pupillary dilation (cyclopentolate 0.5%). The patient interface was docked to the eye without complication: suction caused no wound leakage through increased intraocular pressure. Built-in optical coherence tomography gave a precise scan of the anterior segment. A 4.5-mm round capsulorhexis was created, emerging the fold of the anterior capsule (Fig. 2). Corneal wounds (3.2 mm main corneal incision and the side port) and nucleus liquefaction were performed with the intraocular femtosecond laser treatment. The femtolaser-assisted part of the surgery was followed by conventional, uneventful phacoemulsification cataract surgery with a round, intact, free-floating capsulorhexis. The nucleus could be removed with phacoemulsification and the cortex was aspirated. The anterior capsule tear 624
In traumatic cataract cases, the most common intraocular complications are capsular (anterior and/or posterior) tears, zonular weakness, and rupture of the zonules (3, 4). Anterior capsular tears may extend to the posterior capsule, which can impede good visual rehabilitation (1, 4). In this case, injuries of the anterior capsule and the cornea were demonstrated by Scheimpflug imaging system (Pentacam) (Fig. 1A). This was a useful diagnostic tool to show traumatic changes of both the lens and the lens capsule. How can we provide the best care for traumatic cataract cases? We previously reported that the pupil size must be 1.5 mm larger than the area treated with the laser. A limitation of femtosecond laser use is adequate pupil size (4); however, in the case of narrow pupils, using Malyugin ring proved to be an adequate pupil dilation device during femtolaserassisted cataract surgery (5). The larger pupil decreases the chance of the laser shockwave hitting the pupillary margin. Femtolaser offers a technique for in-the-bag IOL implantation with a higher predictability compared to manual phacoemulsification. This traumatic case report indicates that a femtosecond laser–created capsulorhexis is a safe and effective method even when anterior capsule injury is present. A more precise, perfectly centered, regularly shaped anterior capsulotomy shows better IOL/capsule overlap and results in a more stable, optimal postoperative IOL position (6, 7). This may prevent tilt and decentration of the IOL, inducing less lower and higher order aberrations, providing better optical quality after cataract surgery (8). Manual capsulorhexis could also be performed in this case, but not so precisely and safely. The main benefit of the femtolaser is a perfect, regularly shaped anterior capsulotomy. During the primary care—2 weeks before the cataract surgery—a suture was placed into the wound. Despite corneal sutures, we did not anticipate a problem with corneal wound leakage during the suction or the conventional part of the surgery.
© 2014 Wichtig Publishing - ISSN 1120-6721
Szepessy et al
Fig. 2 - Image of the anterior segment by built-in optical coherence tomography during the intraocular femtosecond laser treatment; 4.5-mm round capsulorhexis (white arrow) was created safely emerging the fold of the anterior capsule.
According to previous data, laser-created corneal incisions and nucleus liquefaction can also be performed precisely in traumatic cataract cases. Liquefaction and fragmentation of the lenses, which allows for chopping the nucleus without the use of phaco energy, cause less corneal swelling in the postoperative period and may cause less trauma to corneal endothelial cells than manual phacoemulsification (2). This is important in traumatic cataract because endothelial cells can be injured during the trauma. Creation of precise anterior capsulotomy and liquefaction/ fragmentation of the lenses are the most important values of using femtosecond laser in traumatic cases. Intraocular femtolaser causes less trauma to the weak zonules and significantly reduces dissipated ultrasound energy during conventional phacoemulsification of cataract surgery. This
traumatic case report shows that intraocular femtosecond laser can be used successfully and safely in creating corneal wounds, anterior capsulotomy, and nucleus liquefaction in traumatic cataract surgery. Financial Support: No financial support was received for this submission. Conflict of Interest Statement: None of the authors has conflict of interest with this submission. Address for correspondence: Zsuzsanna Szepessy, MD, PhD Department of Ophthalmology Semmelweis University Mária Str. 39 1085 Budapest Hungary [email protected]
REFERENCES 5. 1.
2.
3.
4.
Nagy ZZ, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009;25:1053-60. Takács AI, Kovács I, Miháltz K, Filkorn T, Knorz MC, Nagy ZZ. Central corneal volume and endothelial cell count following femtosecond laser-assisted refractive cataract surgery compared to conventional phacoemulsification. J Refract Surg 2012;28:387-91. Marques FF, Marques DM, Osher RH, Osher JM. Fate of anterior capsule tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42. Nagy ZZ, Kránitz K, Takacs A, Filkorn T, Gergely R, Knorz MC. Intraocular femtosecond laser use in traumatic cata-
6.
7.
8.
racts following penetrating and blunt trauma. J Refract Surg 2012;28:151-3. Kránitz K, Takács AI, Gyenes A, et al. Femtosecond laserassisted cataract surgery in management of phacomorphic glaucoma. J Refract Surg 2013;29:645-8. Kránitz K, Takacs A, Miháltz K, Kovács I, Knorz MC, Nagy ZZ. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg 2011;27:558-63. Nagy ZZ, Kránitz K, Takacs AI, Miháltz K, Kovács I, Knorz MC. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg 2011;27:564-9. Miháltz K, Knorz MC, Alió JL, et al. Internal aberrations and optical quality after femtosecond laser anterior capsulotomy in cataract surgery. J Refract Surg 2011;27:711-6.
© 2014 Wichtig Publishing - ISSN 1120-6721
625
Eur J Ophthalmol 2014; 24 ( 4 ): 623-625
case report
Intraocular femtosecond laser use in traumatic cataract Zsuzsanna Szepessy, Ágnes Takács, Kinga Kránitz, Tamás Filkorn, Zoltán Z. Nagy Department of Ophthalmology, Semmelweis University, Budapest - Hungary
Purpose: To report the use of femtosecond laser cataract surgery in a traumatic case. Methods: A 38-year-old man had a penetrating eye injury while working with wire. The corneal laceration was sutured first. In the postoperative period, cortical cataract appeared in the crystalline lens; therefore, in the second session, cataract surgery was performed using a femtosecond laser system (Alcon-LenSx Lasers Inc.). Results: Corneal incisions, an intact 4.5 mm capsulorhexis, and nucleus liquefaction were performed with the femtosecond laser. Corrected distance visual acuity was 0.9 1 month after surgery. Conclusions: Femtosecond laser is an effective method in traumatic cataract cases after penetrating eye injury. Corneal incisions, capsulorhexis, and nucleus liquefaction can be performed precisely and safety. Keywords: Capsulorhexis, Cataract, Femtosecond laser, Trauma Accepted: January 26, 2014
INTRODUCTION Serious eye injuries (blunt trauma and penetrating eye injury) frequently involve the crystalline lens, leading to cataract formation. Associated complications like zonular weakness/rupture and disruption of the anterior/posterior lens capsule may complicate traumatic cataract extraction. With the application of an intraocular femtosecond laser, 3 crucial steps of cataract surgery can be replaced: positioned self-sealing corneal incisions, well-centered, intact circular anterior capsulotomy, and lens fragmentation/liquefaction (1). These steps are important in traumatic cases. Injuries of the anterior capsule make manual capsulotomy difficult; anterior tears may easily extend to the posterior capsule. Capsular complications during cataract extraction can complicate further steps of the surgery and decrease the probability of achieving good long- and short-term postoperative results. Previously published articles reported that reproducibility of capsulorhexis is significantly better with a femtosecond laser in nontraumatic cataracts; however, femtosecond laser has been used effectively during traumatic cataract extraction.
Reducing phacoemulsification energy with the application of a femtosecond laser is also a potential benefit during cataract extraction, reducing further trauma to the corneal endothelial cell layer vs manual phacoemulsification (2). This article presents the successful use of intraocular femtosecond laser in performing corneal incisions, round, intact capsulorhexis, and nucleus liquefaction in traumatic cataract.
Case report A 38-year-old upholsterer had a penetrating eye injury while working with wire, hitting his right eye with it. He removed the penetrating piece of wire from his eye. On admission, uncorrected distance visual acuity was 0.4. Slit-lamp examination showed 3-mm corneal laceration at 10 o’clock paracentrally with a prolapsing iris. The anterior chamber was shallow and the eye was hypotonic. The lens was clear, but after pupillary dilation a fold was found at 10 o’clock on the anterior capsule. By Scheimpflug imaging system (Oculus Pentacam HR 70900; Oculus Optikgeräete GmbH, Wetzlar, Germany), the anterior capsule
© 2014 Wichtig Publishing - ISSN 1120-6721
623
Femtosecond laser use in traumatic cataract
did not extend to the posterior capsule. A 3-piece acrylic intraocular lens (IOL) (+29.0 D-S AcrySof MA60AC, Alcon Laboratories Inc., Fort Worth, Texas, USA) was implanted into the capsular bag. Uncorrected distance visual acuity increased to 0.7 the first postoperative day. One month after surgery, corrected distance visual acuity was 0.9.
DISCUSSION
Fig. 1 - Scheimpflug image (A) and slit-lamp photograph (B) after primary care. (A) By Scheimpflug imaging system (Oculus Pentacam HR 70900; Oculus Optikgeräete GmbH, Wetzlar, Germany), the anterior capsule injury became visible (white arrow). (B) Corneal sutures in place after primary care.
injury became more visible (Fig. 1A). Orbital computed tomography demonstrated no intraocular foreign body. During primary care, the iris was repositioned and the corneal laceration was sutured with two 10-0 interrupted sutures (Fig. 1B). Postoperatively, the visual acuity of the patient decreased due to anterior cortical cataract formation. Two weeks after the primary care, cataract surgery was performed using an intraocular femtosecond laser (Alcon-LenSx Lasers Inc., Aliso Viejo, California, USA). Pupil size was 8 mm after pupillary dilation (cyclopentolate 0.5%). The patient interface was docked to the eye without complication: suction caused no wound leakage through increased intraocular pressure. Built-in optical coherence tomography gave a precise scan of the anterior segment. A 4.5-mm round capsulorhexis was created, emerging the fold of the anterior capsule (Fig. 2). Corneal wounds (3.2 mm main corneal incision and the side port) and nucleus liquefaction were performed with the intraocular femtosecond laser treatment. The femtolaser-assisted part of the surgery was followed by conventional, uneventful phacoemulsification cataract surgery with a round, intact, free-floating capsulorhexis. The nucleus could be removed with phacoemulsification and the cortex was aspirated. The anterior capsule tear 624
In traumatic cataract cases, the most common intraocular complications are capsular (anterior and/or posterior) tears, zonular weakness, and rupture of the zonules (3, 4). Anterior capsular tears may extend to the posterior capsule, which can impede good visual rehabilitation (1, 4). In this case, injuries of the anterior capsule and the cornea were demonstrated by Scheimpflug imaging system (Pentacam) (Fig. 1A). This was a useful diagnostic tool to show traumatic changes of both the lens and the lens capsule. How can we provide the best care for traumatic cataract cases? We previously reported that the pupil size must be 1.5 mm larger than the area treated with the laser. A limitation of femtosecond laser use is adequate pupil size (4); however, in the case of narrow pupils, using Malyugin ring proved to be an adequate pupil dilation device during femtolaserassisted cataract surgery (5). The larger pupil decreases the chance of the laser shockwave hitting the pupillary margin. Femtolaser offers a technique for in-the-bag IOL implantation with a higher predictability compared to manual phacoemulsification. This traumatic case report indicates that a femtosecond laser–created capsulorhexis is a safe and effective method even when anterior capsule injury is present. A more precise, perfectly centered, regularly shaped anterior capsulotomy shows better IOL/capsule overlap and results in a more stable, optimal postoperative IOL position (6, 7). This may prevent tilt and decentration of the IOL, inducing less lower and higher order aberrations, providing better optical quality after cataract surgery (8). Manual capsulorhexis could also be performed in this case, but not so precisely and safely. The main benefit of the femtolaser is a perfect, regularly shaped anterior capsulotomy. During the primary care—2 weeks before the cataract surgery—a suture was placed into the wound. Despite corneal sutures, we did not anticipate a problem with corneal wound leakage during the suction or the conventional part of the surgery.
© 2014 Wichtig Publishing - ISSN 1120-6721
Szepessy et al
Fig. 2 - Image of the anterior segment by built-in optical coherence tomography during the intraocular femtosecond laser treatment; 4.5-mm round capsulorhexis (white arrow) was created safely emerging the fold of the anterior capsule.
According to previous data, laser-created corneal incisions and nucleus liquefaction can also be performed precisely in traumatic cataract cases. Liquefaction and fragmentation of the lenses, which allows for chopping the nucleus without the use of phaco energy, cause less corneal swelling in the postoperative period and may cause less trauma to corneal endothelial cells than manual phacoemulsification (2). This is important in traumatic cataract because endothelial cells can be injured during the trauma. Creation of precise anterior capsulotomy and liquefaction/ fragmentation of the lenses are the most important values of using femtosecond laser in traumatic cases. Intraocular femtolaser causes less trauma to the weak zonules and significantly reduces dissipated ultrasound energy during conventional phacoemulsification of cataract surgery. This
traumatic case report shows that intraocular femtosecond laser can be used successfully and safely in creating corneal wounds, anterior capsulotomy, and nucleus liquefaction in traumatic cataract surgery. Financial Support: No financial support was received for this submission. Conflict of Interest Statement: None of the authors has conflict of interest with this submission. Address for correspondence: Zsuzsanna Szepessy, MD, PhD Department of Ophthalmology Semmelweis University Mária Str. 39 1085 Budapest Hungary [email protected]
REFERENCES 5. 1.
2.
3.
4.
Nagy ZZ, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg 2009;25:1053-60. Takács AI, Kovács I, Miháltz K, Filkorn T, Knorz MC, Nagy ZZ. Central corneal volume and endothelial cell count following femtosecond laser-assisted refractive cataract surgery compared to conventional phacoemulsification. J Refract Surg 2012;28:387-91. Marques FF, Marques DM, Osher RH, Osher JM. Fate of anterior capsule tears during cataract surgery. J Cataract Refract Surg 2006;32:1638-42. Nagy ZZ, Kránitz K, Takacs A, Filkorn T, Gergely R, Knorz MC. Intraocular femtosecond laser use in traumatic cata-
6.
7.
8.
racts following penetrating and blunt trauma. J Refract Surg 2012;28:151-3. Kránitz K, Takács AI, Gyenes A, et al. Femtosecond laserassisted cataract surgery in management of phacomorphic glaucoma. J Refract Surg 2013;29:645-8. Kránitz K, Takacs A, Miháltz K, Kovács I, Knorz MC, Nagy ZZ. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg 2011;27:558-63. Nagy ZZ, Kránitz K, Takacs AI, Miháltz K, Kovács I, Knorz MC. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg 2011;27:564-9. Miháltz K, Knorz MC, Alió JL, et al. Internal aberrations and optical quality after femtosecond laser anterior capsulotomy in cataract surgery. J Refract Surg 2011;27:711-6.
© 2014 Wichtig Publishing - ISSN 1120-6721
625
