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With progressively convalescent beheld rehabilitation afterward avalanche surgery, accommodating expectations of favorable refractive outcomes accept increased, ultimately acute authentic preoperative surgical planning.1 The addition of intraocular lenses (IOLs) that booty into annual corneal assay to actual for preoperative amaurosis has become an advantage in surgical assessments, but bright corneal incisions (CCIs) and their appulse on corneal curvature may abet abnormal postoperative refractive results.2



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There accept been attempts to abbreviate surgically induced amaurosis (SIA) by a array of preoperative calculators and intraoperative techniques.3 Femtosecond laser–assisted avalanche anaplasty (FLACS) was alien to hopefully abet beneath SIA through self-sealing triplanar incisions. Preliminary studies accept accustomed that FLACS offers added authentic antecedent capsulotomy circularity,4,5 beneath phacoemulsification time,5 and a bargain charge for phacoemulsification energy,5,6 conspicuously in patients with abutting nuclear arthritic cataracts.7

The annual of FLACS in attention to aspersing SIA has apparent alloyed results. Zhu et al.8 and Serrao et al.9 acclaimed a decidedly beyond consequence of SIA in cases breadth CCIs were created with the femtosecond laser compared to chiral incisions. These after-effects were accepted to accept been attributed to postoperative CCI edema or due to estimated localization of the femtosecond laser incisions, namely actuality afterpiece to the axial corneal arbor than anticipated.8 In contrast, Mastropasqua et al.10 and a aftereffect abstraction by Serrao et al.11 begin beneath SIA with CCIs created by a femtosecond laser. Finally, Nagy et al.,12 Diakonis et al.,13 Ferreira et al.,14 and Férnandez et al.15 all begin no abnormality in SIA amid their chiral and femtosecond laser cohorts.



Literature investigating SIA amid chiral and femtosecond laser CCIs has advised the LenSx8,10,12–15 or IntraLase iFS9,11 platforms. To our knowledge, there accept been no analytic investigations on the aftereffect of femtosecond laser CCIs created with the Catalys Precision Laser Arrangement (Johnson & Johnson Vision, Santa Ana, CA). The purpose of this abstraction was to analyze the aftereffect of postoperative corneal assay and SIA amid CCIs created manually or with the Catalys femtosecond laser in a distinct Canadian surgical center.

In this attendant accomplice analysis, patients ability avalanche abstraction and IOL commodity from June to September 2018 who were 18 years or earlier were included from a distinct high-volume avalanche center. This abstraction adhered to the credo of the Declaration of Helsinki and was accustomed by the William Osler Health Arrangement Research Ethics Board (ID No. 18-0025). All patients completed a accounting accord anatomy to complete a 1-month and 3-month aftereffect for the purposes of this study.



Exclusion belief were: (1) history of ocular agony or surgery, (2) antecedent corneal anatomy (ie, endothelial dystrophy, adapted apparent brindled keratitis, pterygium, or accepted corneal ulcer), (3) preoperative corneal amaurosis greater than ±3.00 diopters (D), (4) history of systemic ache affecting ocular functioning, (5) circumstantial ocular ache (ie, glaucoma, strabismus, retinopathy, or macular degeneration), and (6) ailing dilating pupils contraindicating FLACS. Patients were removed from antecedent application from admittance if above intraoperative or postoperative complications occurred, corneal incisions were fabricated afield during surgery, or their postoperative Snellen adapted ambit beheld acuity (CDVA) was worse than 20/40.16 A sample admeasurement adding was implemented for 64 patients and 104 eyes, which met adapted ability for an alpha amount of 0.05.

Surgical procedures were performed by four accomplished ophthalmologists (SS, EST, HC, and RM) application accepted surgical equipment. CCIs were created either manually with a 2.5-mm keratome brand or with the Catalys femtosecond laser. The primary chiral and side-port incisions were fabricated at the limbus antecedent to conjunctival vascular arcades. Traditional phacoemulsification (Whitestar Signature PRO; Johnson & Johnson Vision) completed the avalanche extraction. Phacoemulsification ambit were kept constant amid the chiral and femtosecond laser cohorts; there were no differences in preoperative and postoperative administration techniques amid the two groups.

After advancing with the assimilation arena assimilate the accommodating eye, the surgeon manually adapted the advancing apparatus against the limbus above-mentioned to authoritative the primary cavity and side-port guided by the real-time imaging system. The afterward cavity ambit were acclimated throughout the study: distinct intrastromal at a 9-mm optical zone, 20% uncut anterior/posterior portion, 90° ancillary cut angle, 5 µm accumbent atom spacing, 10 µm vertical atom spacing, 5.0 µJ beating energy, 30% antecedent band distance, and a axial band body annual of 4. The laser-assisted capsulotomy was a connected arrangement for a 5-mm bore scanned abridged with a 600-µm cavity depth, accumbent atom agreement of 4 µm, vertical atom agreement of 9 µm, and a beating activity of 4 µJ. The connected lens breach arrangement was division softening, with a bore of 5 mm, anecdotal bendable agreement of 200 µm, filigree agreement of 500 µm, accumbent atom agreement of 10 µm, vertical atom agreement of 40 µm, antecedent beating activity of 8 µJ, after beating activity of 10 µJ, antecedent abridged assurance allowance of 500 µm, and a after abridged assurance allowance of 650 µm. The connected lens breach arrangement included two assay repetitions with a bound bore of 5 mm.

Right eye capital incisions were fabricated at 200° with a limbus annual of 0.3 mm, amplitude of 2.5 mm, breadth of 1.5 mm, no uncut region, 20% uncut anterior/posterior portion, 25 µm uncut axial length, 30% antecedent abyss plane, 70% after abyss even 100° antecedent ancillary cut angle, and a after ancillary cut bend of 45°. The above ambit were acclimated for the adapted eye side-port cavity at 135° axis, 0.8 mm width, 1.2 mm depth, and an antecedent ancillary cut bend of 60°.

Left eye capital incisions were fabricated at 20° with a limbus annual of 0.3 mm, amplitude of 2.5 mm, breadth of 1.5 mm, no uncut region, 20% uncut anterior/posterior portion, 25 µm uncut axial length, 30% antecedent abyss plane, 70% after abyss plane, 100° antecedent ancillary cut angle, and a after ancillary cut bend of 45°. The above ambit were acclimated for the larboard eye side-port cavity at 315° axis, 0.8 mm width, 1.2 mm depth, and an antecedent ancillary cut bend of 60°.

Demographic parameters, comorbidities, and optical biometric abstracts taken by the IOLMaster 700 (Carl Zeiss Meditec, Jena, Germany) were recorded. CDVA, intraocular burden (IOP), corneal cartography (Pentacam; Oculus Optikgeräte GmbH, Wetzlar, Germany), axial corneal array (CCT) (Pentacam), absolute corneal aberrant amaurosis basis (Pentacam), aberrant corneal amaurosis basis (Corneal Analyzer OPD-Scan III; Nidek Co. Ltd, Gamagori, Japan), and antecedent articulation optical adherence tomography (AS-OCT) images (Visante; Carl Zeiss Meditec) were calm from the preoperative and postoperative 1-week (POW1), 1-month (POM1), and 3-month (POM3) time points. AS-OCT images were manually advised by the above artisan to actuate the array of the CCI and the erect ambit from the axial arbor to the alien anguish aperture (EXD). Intraoperative contest and able phacoemulsification times were recorded.

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The primary aftereffect was the beggarly SIA at the POM3 follow-up, bent by comparing the postoperative Pentacam corneal keratometry abstracts at aftereffect to the preoperative Pentacam keratometry measurements. Accessory outcomes included: CDVA, IOP, CCT, Pentacam absolute corneal aberrant astigmatism, OPD aberrant amaurosis index, CCI thickness, EXD, and able phacoemulsification time.

Microsoft Excel and SPSS software (version 23.0; IBM Corporation, Armonk, NY) were acclimated to accomplish all statistical testing, with a P amount of .05 acclimated to announce statistical significance. A ambiguous ciphering blueprint archetypal accounting for within-patient alternation was used. The Alpins agent method, aboriginal declared in 1993 by Alpins17 (VECTrAK program, adaptation 2.4.2), was acclimated to annual the SIA. Correlations amid SIA and CCI and EXD were activated with the Pearson alternation coefficient.

Overall, 104 eyes of 64 patients ability avalanche abstraction and IOL commodity procedures completed by four accomplished ophthalmologists were advised for inclusion. All surgeons adhered to the above aforementioned femtosecond laser and chiral cavity parameters; no statistical differences were acclaimed amid surgeons (Table A, accessible in the online adaptation of this article). No intraoperative contest occurred, and no patients acclaimed postoperative complications affair exclusion criteria. Table 1 summarizes the baseline ambit amid the chiral and femtosecond laser CCI cohorts. Of note, there was a decidedly best axial breadth in the FLACS accomplice compared to the chiral accumulation (P = .04); however, this can be attributed to a best after alcove with a commensurable antecedent alcove depth, and accordingly was not of affair in our assay (Table 1).

Table A:

SIA Stratified by Surgeon

Table 1:

Patient Demographics and Baseline Characteristics

Table 2 summarizes the differences in intraoperative able phacoemulsification time and postoperative SIA, CDVA, IOP, CCT, absolute corneal aberrant astigmatism, and aberrant amaurosis basis at POW1, POM1, and POM3 amid the chiral and FLACS cohort. Notably, there was a decidedly beyond beggarly SIA apparent afterward femtosecond laser CCIs compared to chiral incisions at POW1 (manual: 0.51 ± 0.44 D, FLACS: 0.72 ± 0.49 D, P = .02) and POM1 (manual: 0.46 ± 0.36 D, FLACS: 0.64 ± 0.53 D, P = .04). However, at POM3, there was no cogent abnormality in SIA amid either accomplice (Figure 1). No cogent differences or trends were apparent in arbor of astigmatism, CCT, absolute corneal aberrant astigmatism, or aberrant amaurosis basis at any postoperative appointment (P > .05). CCT, absolute corneal aberrant astigmatism, and aberrant amaurosis basis ethics alternate to baseline levels by POM3 in both cohorts. No cogent abnormality in able phacoemulsification time was apparent (P = .59).

Table 2:

Statistical Assay of Intraoperative and Postoperative Outcomes

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Figure 1.

Comparison of surgically induced amaurosis (SIA) over three postoperative time credibility amid chiral and femtosecond laser– assisted avalanche anaplasty (FLACS) cohorts. *Designates cogent differences. CCI = bright corneal incision; POM = postoperative month

Table 3 summarizes the postoperative CCI assay as bent by the AS-OCT at POM1 and POM3. The chiral accomplice trended to accept a beyond CCI array compared to the FLACS group, with a decidedly thicker chiral cavity armpit acclaimed at POM3 (manual: 744.26 ± 86.03 µm, FLACS: 703.56 ± 56.75 µm, P = .006). No cogent abnormality in the position of the CCI compared to the axial arbor was apparent at POM1 (P = .17) and POM3 (P = .44). Figure 2 demonstrates the affiliation amid SIA and EXD. There was a cogent alternation apparent amid SIA and EXD for both cohorts, with added centrally accumbent incisions demonstrating beyond postoperative SIA ethics (P = .01, r = −0.434).

Table 3:

Postoperative CCI Morphology

Figure 2.

Correlation of surgically induced amaurosis (SIA) and ambit of bright corneal cavity (CCI) to axial corneal arbor at postoperative ages 3 (POM3). D = diopters

The after-effects of our abstraction authenticate a decidedly college beggarly SIA in the femtosecond laser accumulation at POW1 (P = .02) and POM1 (P = .04), but no cogent abnormality in SIA amid the chiral and femtosecond laser groups at POM3 (P = .11). Losing acceptation coincides with the abstract investigating the healing backdrop of femtosecond laser CCIs, which authenticate beneath after anguish retraction and lower endothelial misalignment by the POM3 aftereffect visit.6,18 Of note, the POM3 average SIA was acutely lower in the femtosecond laser accomplice compared to the POM3 beggarly SIA. Figure A (available in the online adaptation of this article) demonstrates how outliers afflicted the beggarly SIA added in the femtosecond laser accumulation compared to a abridgement of outliers in the chiral cohort, arch to a right-skewed FLACS beggarly SIA. The chiral accumulation additionally accustomed right-skewed deviation; however, this was not to the above amount as the femtosecond laser group. This award suggests that a allegory of SIA medians would accommodate a added authentic measure, and one that should be included in approaching studies for a added adumbrative statistical presentation.

Figure A.

Distribution of femtosecond laser–assisted avalanche anaplasty surgically induced amaurosis (SIA) ethics at postoperative ages 3 (POM3).

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AS-OCT imaging is a advantageous apparatus in demonstrating the absolute appulse of femtosecond laser CCIs in allegory to chiral incisions with attention to corneal morphological properties, conspicuously to actuate a accessible assay for the decidedly beyond SIA in the aboriginal postoperative period. Figure B (available in the online adaptation of this article) outlines how the CCI array and EXD ambit were affected by the accomplished technician. The FLACS beggarly CCI array trended to be abate throughout the postoperative period, conspicuously demonstrating a decidedly thinner amount at POM3 (P = .006). In affiliation with the trend for a bargain CCT thickness, an edematous assay for the added SIA in the femtosecond laser CCI accomplice during the aboriginal postoperative aeon is unlikely. Zhu et al.8 accepted that inaccurate accession of the LenSx femtosecond laser advancing apparatus to be added antecedent than accepted may accept contributed to the decidedly beyond SIA in their 2017 analysis. However, the EXD was not decidedly altered at POM1 (P = .17) or POM3 (P = .44) in our analysis. Therefore, the localization of the CCI cavity with annual to the axial corneal arbor was agnate and not a antecedent of corneal astigmatic change. This cessation is constant with the 2017 abstraction by Bala et al.,19 who bent that femtosecond laser primary CCIs were created in abutting adjacency to their accepted location. Bala et al. did agenda that admitting reproducibility in agreement of cavity breadth and width, accessory incisions were accountable to capricious eye angle and displacement of the advancing apparatus of the LenSx platform.19 The absolute appulse of the accessory cavity on SIA is an breadth of absorption for added assay to actuate the assay of aboriginal postoperative added SIA with Catalys FLACS.

Figure B.

Anterior articulation optical adherence tomography (AS-OCT) angel demonstrating bright corneal cavity (CCI) and ambit of CCI to axial corneal arbor measurements. EXD = alien anguish opening

Introduced in 1993,17 the Alpins agent adjustment for SIA assay has accustomed authentic clay for free the consequence of keratometric change and arbor of amaurosis about-face afterward avalanche surgery. The 2004 address by Alpins and Goggin20 graphically categorical the annual of agent assay and how to accomplish a ambition amaurosis afterward avalanche surgery. By comparing the postoperative abnormality in collapsed and abrupt keratometry to the abnormality in preoperative keratometry axes, and acquainted the arbor of amaurosis for anniversary time point, the SIA and arbor of astigmatic change can be affected (Figure C, accessible in the online adaptation of this article).20 By application a monofocal aspheric IOL implant centered in the capsular bag that does not actual for preoperative astigmatism, the all-embracing change from preoperative to postoperative amaurosis was attributed to SIA. A 2001 analytic appraisal of amaurosis alteration through laser refractive anaplasty by Alpins bent that the agent adjustment can actuate SIA through corneal keratometry values; however, abnormality of SIA may be apparent due to adjustment of the cornea afterward surgery.21 With the aesthetic agent assay model, our statistical assay offers a reliable assay of SIA afterward chiral and femtosecond laser CCIs.

Figure C.

Graphical affirmation of Alpins vector-method adding of surgically induced amaurosis (SIA). D = diopters

There are several limitations to this study. Assorted patients had both eyes enrolled in this study, accordingly introducing intraobserver correlation. To absolute bent because both eyes are not absolutely independent, a beeline corruption archetypal demography into annual within-patient alternation was acclimated in statistical analysis. The sample admeasurement adding implemented additionally took this agency into annual and met adapted ability with 64 patients and 104 cases. Second, the altitude of AS-OCT images was abstract to the accomplishment of the technician. To abbreviate any airheadedness amid measurements, the above accomplished artisan manually abstinent the CCI array and EXD ethics for anniversary image. For affection control, one columnist (AP) advised every AS-OCT angel to affirm bendability beyond all readings. Finally, admittance of assorted surgeons introduces airheadedness amid cases, conspicuously for the able phacoemulsification time outcome. Anniversary surgeon was accomplished with application the Catalys femtosecond laser and adhered to the agreement for anniversary case.

There was no cogent abnormality in SIA amid FLACS with the Catalys femtosecond laser and chiral avalanche anaplasty at POM3. Femtosecond laser CCIs led to decidedly abate CCI thickness, and trended against bargain CCT and commensurable CCI position compared to chiral corneal incisions.

Patient Demographics and Baseline Characteristicsa

Statistical Assay of Intraoperative and Postoperative Outcomesa

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Postoperative CCI Morphologya

SIA Stratified by Surgeon

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