Improving Outcomes with Laser-Assisted Surgery

Use of a femtosecond laser brings many opportunities for improving outcomes of cataract and refractive lens exchange surgery, said H Burkhard Dick MD, PhD, explaining his preference for a laser-assisted approach in these procedures.

Professor Dick described several benefits of laser-assisted surgery in eyes with hyperopia or high myopia, as well as capsulotomy in both situations.

“Capsulotomy done with the laser instead of a physical instrument reduces the risk of injuring the endothelium or lens capsule when operating on hyperopic eyes that have a crowded, shallow anterior chamber,” Prof Dick explained. “In addition, the laser creates a perfectly centred and well-sized capsulotomy that will overlap the IOL optic and therefore enable accurate IOL positioning and decrease deviation from target refraction in these eyes that are particularly susceptible to refractive surprises.”

Should the case become complicated by posterior capsule rupture, the perfectly sized, positioned, and circular capsulotomy created with the laser will also enable secure placement of the optic using optic capture, he noted.

Additionally, using the laser for lens fragmentation will allow for safer and more efficient lens removal. The reduced fluid turbulence and ultrasound energy usage result in less postoperative corneal oedema, Prof Dick said.

Regarding surgery in highly myopic eyes, Prof Dick said using the laser for capsulotomy overcomes the challenges presented by a capsular bag that tends to be large and floppy and only appears to be smaller and farther away. Furthermore, the ability to create an optimally sized capsule opening that helps maintain IOL stability by fully overlapping the optic is a particular benefit in highly myopic eyes that are at increased risk for decentration over time.

The advantages of performing laser lens fragmentation in high myopes are similar to those associated with its use in hyperopic eyes. The gentle lens removal also causes less vitreous traction, which Prof Dick said is important considering the increased risk for retinal detachment in high myopes.

He added that laser lens fragmentation has an additional advantage in cases of refractive lens exchange because it allows the manual portion of the procedure to be performed without either ophthalmic viscoelastic device (OVD) or ultrasound.

“Without the need for OVD, the procedure is shorter, and there is less iris/lens diaphragm movement,” Prof Dick explained. “With this approach, patients benefit with greater comfort, faster visual rehabilitation, and no risk for a postoperative IOP spike caused by residual OVD.”

The laser provides further opportunities for more precise astigmatic correction—whether it is to create arcuate incisions or markings on the cornea or capsule to guide toric IOL alignment, which he said also avoids parallax error and allows evaluation of postoperative IOL rotation.

Surgeons using a femtosecond laser can easily, quickly, and safely create a primary posterior capsulotomy capable of tremendously reducing the incidence of posterior capsule opacification and thus the need for Nd:YAG capsulotomy.

“Primary posterior laser capsulotomy has a particular benefit for centres that do a lot of refractive lens exchange procedures, where patients with full depth of focus simultaneous vision IOLs almost routinely return for Nd:YAG capsulotomy,” Prof Dick said.

Prof Dick spoke at the 2025 ASCRS annual meeting in Los Angeles.

H Burkhard Dick MD, PhD, FEBOS-CR is Professor and Chairman, Department of Ophthalmology, University at Bochum, Germany. burkhard.dick@kk-bochum.de