Femtosecond Laser: Techniques & Technology Ashok Garg, Jorge L Alio, Eric D Donnenfeld
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1FEMTOSECOND LASER Techniques and Technology
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3FEMTOSECOND LASER Techniques and Technology
Editors-in-Chief
Ashok Garg MS PhD FRCS FIAO (Bel) FRSM ADM FAIMS FICA International and National Gold Medalist Chairman and Medical Director Garg Eye Institute and Research Centre Dabra Chowk Hisar, Haryana, India
Jorge L Alió MD PhD Professor and Chairman of Ophthalmology Medical Director VISSUM, Instituto Oftalmologico de Alicante Avda de Denia S/n 03016 Alicante, Spain
Guest Editor
Eric D Donnenfeld MD FACS Clinical Professor Ophthalmic Consultants of Long Island Rockville Center, New York -11570 USA
4Honorary Editors
A John Kanellopoulos MD Medical Director Laservision gr Institute 17-Tsocha Street Athens, Greece-11527
Carlo F Lovisolo MD Medical Director QuattroElle Eye Center Via Cusani, 7-9, 20121 Milano, Italy
Aylin Kilic MD Kudret Goz Hastanesi Kennedy Caddesi No.71 Kavaklidere-Ankara Turkey
Frederic Hehn MD Chief and Medical Director Centre de La Vision, Nations-Vision 23, Boulevarde de L'europe 54500, Vandoeuvre France
Mark Wevill MD 81 Grange Road Dorridge B-93 8QU United Kingdom
Francisco Sanchez Leon MD Director Instituto Oftalmologico Novavision Av Lomas Verdes 464 Naucalpan, Edo Mexico Mexico CP53120
Mahipal S Sachdev MD Chairman and Medical Director Centre for Sight B-5/24, Safdarjung Enclave New Delhi, India
Arun C Gulani MD Director Gulani Vision Institute 8075, Gate Parkway (W) Suite 102 Jacksonville, Florida 32216 USA
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Sharad Lakhotia MS Director Lakhotia Eye Centre Laser Institute E-544, Greater Kailash Part-II New Delhi, India
C Banu Cosar MD Associate Professor of Ophthalmology Sinpas Aqua City 1, Etap H Block D: 13, Cekmekoy 34773 Istanbul, Turkey
Bojan Pajic MD Chairman and Medical Director Swiss Eye Research Foundation Eye Clinic Orasis, Titlisstrasse 44 5734 Reinach AG Switzerland
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© 2012, Jaypee Brothers Medical Publishers
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This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editor specifically disclaim any damage, liability, or loss inc urred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the editor. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
Femtosecond Laser: Techniques and Technology
First Edition: 2012
9789350258767
Printed at:
7DEDICATIONS
Dedicated to
Ashok Garg
Dedicated to
Jorge L Alió8
9Contributors 11Foreword
Within the last decade, femtosecond laser technology has quickly blossomed from a nascent technology for flap creation during laser in situ keratomileusis to application in other field of cornea surgery, cataract surgery and most recently, diagnostic applications. The rapid incorporation of the femtosecond laser is due to the decreased trauma, greater precision, greater flexibility and increased safety compared to mechanical methods. The femtosecond laser seems to have applications for the outer in internal ocular structures.
In the cornea, the femtosecond laser can create incision architecture for keratoplasty for a variety of geometric patterns that are not necessarily repeatable even by a skilled surgeon. A more facile channel can performed for inserting corneal rings in the already compromised keratoconic cornea. A natural extension is use in corneal crosslinking. Application of the femtosecond for implantation of corneal inlays has been reported. Astigmatic keratotomy is yet another application can be performed by this laser.
Moving further into the eye, the femtosecond is currently being used for cataract surgery. In fact, the one of the most technically demanding aspects of the surgery can now be performed with the femtosecond. Although cataract surgery is already one of the most successful surgical procedures in medicine, safety outcomes may increase with the incorporation of “femtosecond laser cataract surgery”. Dynamic light scattering and photon correlation spectroscopy allow the study of vitreoretinal changes to due to common pathology such as macular degeneration and diabetes.
As with any new technology, questions arise regarding economics, clinical flow and the nuances of incorporation into the daily routine. However, surgeon and patient experience over time will address these questions. Furthermore, any new surgical procedure has it is own set of complications, the femtosecond will be no different. However, the current focus is education of surgeons worldwide to provide guidance and mitigate adverse events and adverse experiences. This is the focus of this book.
The book highlights the surgical advances and diagnostic techniques outlined above from some of the most experienced surgeons worldwide. A host of topics are addressed that guide the reader through this rapidly evolving technology and the most current applications. The wide variation in application underlies the fact that there is an exciting future ahead for this technology.
I congratulate Professor Ashok Garg, Professor Jorge L Alió the Chief Editors and their dedicated team of editors and contributors who have made this book an excellent companion for refractive surgeons in their day-to-day clinical practice. I am sure, this is first fine book on Femtosecond Laser at an International level.
Alaa El-Danasoury frcs
Professor of Ophthalmology
Magrabi Eye and Ear Hospital Jeddah
Khozam Street Kilo-3, Mekkah Road
PO Box 7344, Jeddah 21462
Kingdom of Saudi Arabia
E-mail: malaa@magrabi.com.sa12
13Preface
Refractive Surgery technology has undergone rapid advancements and innovations in last two decades. The latest innovation especially Femtosecond Laser offers new possibilities in the field of minimally invasive corneal surgery. Femtosecond Laser employs near infrared pulses to cut tissue with minimal collateral tissue damage. The highly localized tissue effect of low energy Femtosecond Laser shall expand the capabilities and precision of this technology in near future and may be used to create three-dimensional intrastromal resection with micron precision. The Femtosecond Laser has proved its versatility in Lamellar keratoplasty, customized trephination in penetrating keratoplasty, tunnel creation for intracorneal ring segments, astigmatic keratotomy for keratoprostheses, non-invasive trans-scleral glaucoma surgery, retinal imaging presbyopic surgery and cataract surgery. Advances in ultrafast laser technology continued to improve the surgical safety, efficiency, speed and versatility of Femtosecond Lasers in Ophthalmology.
Femtosecond Laser: Techniques and Technology, the first of its kind in world ophthalmology has been planned in such a way to provide complete insight of this technology in various ocular indications. The international experts of this field have covered the present and futuristic uses of this technology in ophthalmology in a step-by-step and lucid manner. Practically, the possible uses of Femtosecond Laser in anterior and posterior segment indications of ophthalmology have been explained for the benefits of ophthalmologists worldwide.
We are highly thankful to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-Publishing) and all staff members of our publisher M/s Jaypee Brothers Medical Publishers Pvt Ltd, New Delhi, India, who took keen interest in this project and for speedy completion of this mega task.
We hope that the book shall meets the expectations of ophthalmologists and shall serve as Quick look Reference Book, for eye surgeons worldwide to sharpen their surgical skills.
Editors
19Guest Editorial  
Femtosecond Laser-An Introduction
Eric D Donnenfeld (USA)
As a practicing ophthalmologist for close to a quarter of a century, I have observed, and been part of, several landmark events in ophthalmology. During my residency training, I was able to watch surgery go from intracapsular to extracapsular this was followed by the advent of intraocular lenses. Later, I was able to take place in the revolution of small-incision surgery with the adoption of phacoemulsification. Finally, over the last 15 years, I have participated in the refractive corneal revolution, with the excimer laser, PRK, and LASIK. These landmark events have changed the course of ophthalmology, and have redefined our ability to treat patients and provide safe and effective visual rehabilitation from cataract surgery and refractive errors.
Today, we are on the verge of another important moment in ophthalmology; the emergence of femtosecond laser refractive cataract surgery. Only time will tell, if this becomes a landmark event. However, femtosecond laser refractive cataract surgery has the potential for being one of these rare moments where the course of ophthalmology changes dramatically due to the advent of new technology. In the past, intraocular lenses and phacoemulsification took years to become safe and effective. With femtosecond cataract surgery, we are moving from an analog to a digital treatment of cataracts, and I am hopeful that femtosecond refractive cataract surgery will level the playing field for all cataract surgeons. Early evidence suggests that this technology will provide better efficacy and safety right from day one.
My experience with femtosecond laser refractive cataract surgery has been one year and almost 1000 cases. As with any new technology, there is an increased chair time preoperatively. Now we discuss surgical options, such as phacoemulsification versus femtosecond laser cataract surgery, as well as having a conventional and premium intraocular lens discussion. In addition, there is an increased time in the operating room due to the laser and conventional cataract surgery. Most importantly, however, complications have been rare to date and the refractive and visual results have been superb. Overwhelmingly, the surgery has met my expectations for safety and efficacy. In my opinion, the greatest benefit of this technology has been a perfect capsulorhexis and the arcuate incisions. I have found that this technology is very helpful for mature lenses and weak zonule cases that were surgically demanding previously, and have now become easier with the advent of laser surgery.
In my experience, refractive outcomes have definitely improved. However, more data is necessary before we can determine the true efficacy of this procedure. One of the most interesting aspects of the surgery has been the way patients have overwhelmingly embraced laser refractive cataract surgery. As with any new technology, I am certain that there will be unexpected hurdles for all of us in the adoption of femtosecond laser refractive cataract surgery. However, if my early experience is any indicator, I believe that this technology is here to stay. The true test will be surgical outcomes and whether femtosecond refractive cataract surgery improves safety and efficacy for all surgeons and most importantly our patients. I hope that five years from now we look back at femtosecond laser refractive cataract surgery as a landmark event in ophthalmology.