MAR 14, 2014
The authors describe a femtosecond laser capsulotomy technique to ensure a continuous 360-degree cut with a free disk and allow identification of tags that may cause radial tears.
Though I have modest experience (around 100 cases), Dr. H. Burkhard Dick has done 2,000 without a break in the capsule. The concept follows the dictates of the Little Rhexis Rescue Maneuver and makes a lot of sense. This technique is needed in the femto world, in my humble opinion.
In the first step of this technique, the paracentesis is opened with a blunt cannula attached to a balanced salt solution or an ophthalmic viscosurgical device (OVD) syringe. A good homogeneous fill of OVD is injected to maintain the anterior chamber. The cannula is advanced to the middle of the lens capsule, and pressure is applied. This downward motion indents the capsule disk, pulling it gently centrally and separating the free edge from the surrounding peripheral capsule to allow confirmation of a continuous 360-degree cut with a free flap.
If a tag is present, this maneuver will identify its location and usually “pop” it free without causing a radial tear. The authors write that this “dimple-down” technique has been used in more than 500 video-documented cases without complication. In the last 500 cases reviewed, tags were discovered and corrected without occurrence of a tear in seven cases (1.4 percent). No capsule tears have resulted from femtosecond capsule tags using this technique, which the authors use in every case of femtosecond laser capsulotomy as a preventive maneuver.
They note that other approaches to identify a continuous femtosecond laser capsulotomy have flaws. The phaco-first technique aspirates the capsule disk and risks pulling the capsule upward before it is confirmed free, while circumferential maneuvers that simulate the motion of a manual capsulorhexis depend on identifying the direction and location of the discontinuity, which is unknowable.