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Anterior capsule integrity after femtosecond laser–assisted cataract surgery

Roberts, Timothy V. MB BS, MMed, FRANZCO, FRACS; Lawless, Michael MB BS, FRANZCO, FRACS; Sutton, Gerard MB BS, MD, FRANZCO, FRACS; Hodge, Chris BAppSc

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Journal of Cataract & Refractive Surgery: May 2015 - Volume 41 - Issue 5 - p 1109-1110
doi: 10.1016/j.jcrs.2014.11.044
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A key driver of the uptake of laser cataract surgery has been the reported safety, accuracy, and predictability of the laser capsulotomy.1–3 The increasing use of presbyopia-correcting and toric intraocular lenses (IOLs) has focused attention on the quality of the capsulotomy because these IOLs require optimum centration to maximize the desired refractive and optical result.

Anterior capsule tears have been reported during the learning curve with laser cataract surgery; however, most studies reporting capsule complications in cases performed by experienced surgeons report very low rates.4 Abell et al.5 report a high rate of anterior capsule tears (1.8%) using the Catalys system (Optimedica), and the authors suggest a possible relationship between eye movement, aberrant pulses, and the observed increased risk for anterior capsule tears in their study. They hypothesize that this finding might be the result of a “germinative capsular defect produced by the laser,” irrespective of the specific femtosecond laser platform used, which might render the “laser-cut capsule intrinsically weak.” More recently in this journal, Day et al.4 describe an anterior capsule tear rate of only 0.10% in a large cohort using the same system, albeit with updated software that has reduced the time to create the capsulotomy. Although software developments might have partially mitigated the findings, the authors believe the results now represent the current abilities of the laser to create safe, strong capsulotomies.

We provide a follow-up report of a large cohort of 3355 consecutive cataract/refractive lens exchange procedures performed at our facility with the Lensx system (Alcon Laboratories, Inc.) between April 2012 and October 2014 as part of a larger ethics-approved prospective interventional case series. A break in the capsule rim was identified in 7 (0.21%) of 3355 cases, occurring during phacoemulsification in 6 eyes and during irrigation/aspiration in 1 eye. In 2 cases, the tear extended to the posterior capsule. One of these cases required anterior vitrectomy, and sulcus IOL implantation was safely performed in both cases. In 2 cases, the tear extended to the equator without posterior capsule involvement or vitreous loss, and in-the-bag IOL implantation was successfully performed with the haptics aligned away from the tear. All tears were observed after phacoemulsification or cortical removal in cases with no predisposing conditions (eg, pseudoexfoliation syndrome, previous trauma, white cataract, or high vitreous pressure) recorded.

The results from our group practice reflect a range of cases from relatively uncomplicated to complex, which we believe would be indicative of the real-life situation for ophthalmologists in normal clinical practice. The rate of 0.21% in this study is comparable to, but slightly better than, the rate of 0.31% in our earlier study of 1300 consecutive cases.3 This would indicate that after an initial learning curve, consistent, predictable, and safe outcomes are achievable and are the norm with laser-assisted cataract surgery. Recent software and hardware advances further augment the ability of the surgeon to deliver optimum outcomes.

All commercially available laser platforms have in common a variation of an anterior segment imaging system, laser generator, treatment algorithm, and patient interface to image, calculate, and deliver the laser, respectively. The specific technology differs between the individual platforms with proprietary laser characteristics and treatment algorithms, energy outputs, and different docking systems. During our study, a curved rigid patient interface was used in 734 cases, and the newer Softfit patient interface in 2621 cases. An anterior capsule tear occurred in 5 cases with the rigid curved interface and 2 cases with the newer patient interface (P=.007). It is difficult to interpret the true clinical significance of this finding because of the low number of anterior capsule tears; however our experience is that the Softfit patient interface and updated laser software of the Lensx system have led to improved outcomes, with a free-floating capsulotomy seen in almost 100% of cases (unpublished data).

Our results indicate no clinical evidence of intrinsic weakness in laser-cut capsules but rather that a small number of eyes have a naturally weak capsule, rendering them susceptible to a tear during surgical manipulations with a manual capsulorhexis or a laser capsulotomy. The use of laser cataract surgery technology, however, would appear to minimize the potential for capsulotomy-related complications.


1. Kránitz K, Miháltz K, Sándor GL, Takacs A, Knorz MC, Nagy ZZ. Intraocular lens tilt and decentration measured by Scheimpflug camera following manual or femtosecond laser-created continuous circular capsulotomy. J Refract Surg. 2012;28:259-263.
2. 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;27:564-569.
3. Roberts TV, Lawless M, Bali SJ, Hodge C, Sutton G. Surgical outcomes and safety of femtosecond laser cataract surgery; a prospective study of 1500 consecutive cases. Ophthalmology. 2013;120:227-233.
4. Day AC, Gartry DS, Maurino V, Allan BD, Stevens JD. Efficacy of anterior capsulotomy creation in femtosecond laser–assisted cataract surgery. J Cataract Refract Surg. 2014;40:2031-2034.
5. Abell RG, Davies PEJ, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior capsulotomy integrity after femtosecond laser-assisted cataract surgery. Ophthalmology. 2014;121:17-24.
© 2015 by Lippincott Williams & Wilkins, Inc.