A Worthy Trio

I have worked in a private hospital setting in the United Kingdom for 21 years. In our hospital, which is located approximately 20 miles outside of London, we perform 1,500 cataract surgery procedures annually. We have been performing laser-assisted cataract surgery (LACS) with the Victus femtosecond laser (Technolas Perfect Vision, a Bausch + Lomb Company) for 3 years. In a lot of those cases, I use the laser in combination with the Stellaris Vision Enhancement System and the EyeCee One Preloaded IOL (both by Bausch + Lomb). Below I share insights into my experience with this trio of products providing superb postoperative outcomes.

LASER PROCEDURE

One thing that I particularly like about the Victus in comparison to other laser platforms for cataract surgery is its friendly curved patient interface. I simply place it on the eye, center it, and engage the suction. After suction is engaged, the docking is simply a matter of raising the patient to meet the cone of the interface. Due to the system’s Intelligent Pressure Sensors, which provides real-time monitoring of the curved patient interface with the eye, a soft dock is achieved. Designed to reduce applanation of the cornea, this feature minimizes the presence of wrinkles on the cornea.

Another benefit of the Victus is that the process itself is virtually painless to the patient. In a recent study comparing patient comfort during LACS with the Victus platform to patient comfort during standard cataract surgery, the majority of patients preferred the laser. In all 20 patients enrolled in the study, LACS was performed in one eye and standard cataract surgery in the other.

Capsulotomy. The automatic recognition software of the Victus femtosecond laser works exceptionally well. In every LACS case I perform, I switch off the treatment overlay during capsulotomy in order to better see the surgical field. While the laser capsulotomy is being performed, I confirm the presence of air bubbles all around the capsulotomy in order to confirm completeness and also look at the OCT image breaks in order to verify that the capsulotomy is complete. This portion of the procedure lasts only a few seconds.

Lens prefragmentation. Next, I perform laser lens prefragmentation. For moderately dense cataracts, I choose the cross-hatch (grid) pattern. First, the air bubbles appear at the deepest part of the lens and travel upward toward the anterior capsule. This step is also quick, lasting around 12 seconds.

In our hospital, the laser suite and operating room are adjacent. Once lens fragmentation is complete, a member of our surgical staff leads the patient from the laser suite and into the operating room for phacoemulsification and IOL implantation.

SURGICAL PROCEDURE

In the majority of LACS case that I have performed, I have not found any significant subconjunctival hemorrhage from the suction ring of the Victus.After opening the corneal wound, I first collapse the center of the anterior capsule by pushing on it with a viscoelastic cannula in order to ensure full separation of the capsulotomy. Then I continue pressing/passing the cannula through one of the central grooves made by the laser and inject OVD deep into the groove in a technique that I call visco chop (Figure 1). This splits the lens in half and releases the air from behind the nucleus. The releasing of the air aids in hydrodissection and avoids capsular rupture.

Hydrodissection. At this point, the lens is really mobile, and hydrodissection can be easily achieved. As an aside, I have found that, with LACS, hydrodissection tends to be a little easier than it is during standard cataract surgery. I believe this is because of the way the air disrupts the cortex. I then chop the nucleus in half again, creating four quadrants of similar size.

Phacoemulsification. For denser cataracts, I would not use a zero phaco technique. However, the amount of phacoemulsification I need to remove the cataract is considerably less than it would have been without prefragmentation with the Victus.

I use high vacuum (600 mm Hg), which most people would frown at, but am able to maintain a perfectly stable anterior chamber. With the high vacuum, I only use very low ultrasound power.

Irrigation/aspiration. Because the lens is almost welded around the edge of a laser capsulotomy, irrigation/aspiration can be a little more challenging than it is during a manual cataract surgery procedure. Although this stage can take a little longer than normal, the Capsule Guard I/A silicone tip (Bausch + Lomb) is helpful because it is gentle and kind to the capsule.

IOL implantation. I implant the EyeCee One Preloaded IOL (Figure 2) with a single-handed technique. In my experience, it is the easiest and the most friendly preloaded injection system available today because it requires only two steps: First, the cartridge of the injector is filled with a low molecular weight OVD; second, the plunger is engaged to release the IOL from the cartridge. Although the recommended incision size is 2.4 mm, in my experience, the EyeCee preloaded injector fits through a 2.2-mm incision and injects the IOL into the bag in a single continuous motion.

During injection, I support the eye with a Sinskey hook placed through the paracentesis. As the IOL unfolds into the eye, I use the plunger to manipulate the lens into the capsular bag, avoiding the need to come out of the eye to get another instrument.

As has been my overall experience with the EyeCee to date, the lens centers beautifully. With the haptics located 90º to the optic, centration of this lens is truly amazing.

CONCLUSION

The more Bausch + Lomb products I use, the more I realize how well they work together to produce excellent refractive results. This is true in not only standard cataract surgery but also in premium cataract surgery. I have had much success with the trio of the Victus femtosecond laser, the Stellaris Vision Enhancement System, and the EyeCee One Preloaded IOL, and I envision using this combination in many more cases.