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Inside Eyetube.net | Oct 2012

The FRCS Concept

An overview of one surgeon's approach to managing complications of laser cataract surgery.

In the corner of the world I come from, culture dictates that destiny and effort determine life and its happenings. In early 2010, my visit to Bogotá, Columbia, to observe Luis A. Ruiz, MD, performing Intracor led me to discover the wonder of laser cataract surgery.

Shortly thereafter, in October 2010, I used the same instrument, now known as the Victus femtosecond laser (Technolas Perfect Vision GmbH and Bausch + Lomb), in a series of patients to create capsulotomies. This study, performed with the appropriate institutional approvals, was used by the companies to obtain the Conformité Europeénne (CE) Mark and US Food and Drug Administration (FDA) clearance to perform capsulotomy with the Victus.

My study in 62 eyes, of which 31 underwent capsulotomy with the Victus and 31 underwent manual capsulotomy with a 26-gauge needle, showed that the diameter (mean, 5.5 ±0.12 mm), centration (95 ±37 μm) and circularity (0.97 ±0.01%, where 1.0 denotes a perfect circle) of the capsulotomies created with this device were excellent.1

Now, having completed more than 1,000 femtosecond refractive cataract surgery (FRCS) procedures, I have learned a lot more than how to create a perfect capsulotomy with the laser. Through trial and error, I have devised a surgical approach that I believe is safer and more efficient than conventional cataract surgery. Below, I describe several common complications and my approach to these issues.


Docking. Docking the patient interface of the Victus is easy. Four senior surgeons and later two junior surgeons at our institution have compared the ease of docking, and all agreed there is no learning curve. In the more than 1,000 cases that have been performed at our practice, there was only one suction loss after capsulotomy.

Anterior capsular tags. In my study of 31 eyes, there were no resultant tags during capsulotomy. However, after other surgeons in our practice started noticing tags, we realized that soft docking is gentler on the eye and can avoid tag formation. After integrating this technique, no surgeon has had further issues with tags.

Free-floating capsules. In my study, 60% of capsules were free-floating. In one case, a patient with a free-floating capsule was flown to a different city for live surgery 24 hours after the capsulotomy was created. There were no IOP spikes, and the change from pre- to postoperative endothelial cell count was minimal.

Anterior radial tears. After my study, I transitioned from careful removal of the freed capsule to using the phaco tip to aspirate it. Using this technique, approximately 1% of patients had a resultant anterior radial capsular tear, but in these cases phacoemulsification could be easily completed after reducing the bottle height.

Posterior capsular rupture. I always keep the laser ablation 1,000 μm away from the posterior capsule, which is the primary reason why I have never had any posterior capsular ruptures or dropped nuclei. In my early cases, I used hydrodissection and had no problems. I do not perform hydrodissection with my current technique, but sometimes I use hydrodelineation.

Miosis. If the capsulotomy diameter is too near to the pupillary margin, it will invariably lead to miosis. My approach is to first use intracameral adrenaline; if the patient does not respond (approximately 1% of cases), I use iris retractors under topical anesthesia and have had no pain complaints from patients.

Intumescent cataract. It is safest to perform only capsulotomy, not fragmentation, with the femtosecond laser in the presence of an intumescent cataract. I have found FRCS to be most beneficial in these cases.

Grade 1 to 5 dark brown cataracts. For grades 1 and 2, I perform only the capsulotomy with the femtosecond laser; for grades 3 through 5, I perform capsulotomy and fragmentation. For grade 5+ dark brown cataracts, a 6.5-mm capsulotomy is created, not only in phaco situations but also in some small-incision cataract surgical cases. A case with a calcified cataract is shown in Figure 1.

Pediatric cataracts. I have found the microscope of the Victus extremely helpful for conducting pediatric surgeries under general anesthesia. Sixteen months into performing FRCS, I have completed eight pediatric surgeries (Figure 2), all of which had perfect capsulotomies. I had to re-dock in one 8-year-old patient after posterior capsular polishing to perform a posterior capsulotomy.

Posterior polar cataracts. In moderate to severe posterior polar cataracts, only capsulotomy is done with the femtosecond laser.

Implantation of an accommodating IOL. I believe capsulotomy is the most important step before Crystalens (Bausch + Lomb) implantation. By incorporating laser capsulotomy into my surgical technique in these cases, my confidence level has gone up and my numbers have increased.


The Victus platform is a versatile system that can be used for cataract, refractive, and therapeutic applications. For cataract surgery, its real-time optical coherence tomography functions, its curved patient interface and intelligent pressure sensors, and the attached microscope with a friendly docking device (Figure 3) give me a great sense of safety and security when handling my patients.

Kasu Prasad Reddy, MD, practices at Maxivision Eye Centre in India. Dr. Reddy states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: kasuprasadreddy@gmail.com.

  1. Auffarth GU, Reddy KP, Ruiz LA. Preliminary clinical results of the Customlens femtosecond laser cataract procedure using the Technolas Femtosecond Workstation. www.technolaspv.com/dasat/Index.php?cid=100858. Accessed September 30, 2012.