Lens capsule-related complications in femtosecond laser-assisted cataract surgery: a study based on video analysis

Abstract

PurposeTo analyse the occurrence and potential causes of lens capsule-related complications during femtosecond laser-assisted cataract surgery (FLACS).MethodsThis prospective consecutive cohort study included the first 1600 eyes (from 1140 consecutive patients) who received FLACS performed by the same surgeon from May 2015 to December 2018. The potential causes and characteristic signs of capsulotomy-related complications, including incomplete capsulotomies and radial anterior capsule (AC) tears, were summarised based on the agreement of two ophthalmologists after they analysed the surgical videos. Subgroup analysis was conducted to characterise the capsulotomy learning curve.ResultsOf the 1600 eyes, 52 (3.25%) had incomplete capsulotomies and 22 (1.38%) had radial AC tears. The most common causes of incomplete capsulotomies were eye tilt (16 eyes, 30.77%), air bubbles or ocular secretions at the interface (14 eyes, 26.92%) and white cataracts (7 eyes, 13.46%). Additionally, 54.55% (12/22) of AC tears were due to incomplete capsulotomy and secondary capsulorhexis. A significant difference was noted between the first 200 eyes and subsequent groups in terms of the incidence of incomplete capsulotomies. No difference was observed in the incidence of AC tears after the initial 100 procedures.ConclusionThe most common causes of incomplete capsulotomies were eye tilt and air bubbles or ocular secretions at the interface. Secondary capsulorhexis after incomplete capsulotomy is the main risk factor for AC tears. There was a steep learning curve for laser capsulotomy in the first 100 operated eyes, as evidenced by the higher complication rate, but this stabilised after 200 procedures.

Application of Femtosecond Laser in Challenging Cataract Cases

“…Other studies also showed the presence of a steep learning curve in the initial 100 to 200 FLACS cases, with an increased risk of complications, including incomplete capsulotomy. 90,91 However, stabilization of complication rates was observed after 200 FLACS cases. 90,91 Of note, FLACS may require additional time and effort for both surgeons and patients because it is associated with an increased duration of cataract surgery, and it requires the transport of the patients or microscope during surgery.…”

“…90,91 However, stabilization of complication rates was observed after 200 FLACS cases. 90,91 Of note, FLACS may require additional time and effort for both surgeons and patients because it is associated with an increased duration of cataract surgery, and it requires the transport of the patients or microscope during surgery. As there is still a controversy regarding the superiority in the visual and refractive outcomes of FLACS, 5,[36][37][38][39] expert cataract surgeons may not choose to use FLACS for general cataract cases.…”

“…Bali et al 89 reported that the first 200 cases of FLACS were associated with complications such as suction break (2.5%), anterior capsular tag (10.5%), anterior radial tear (4%), posterior capsular rupture (3.5%), and lens dislocation (2%), which are even higher rates than those of conventional cataract surgery. Other studies also showed the presence of a steep learning curve in the initial 100 to 200 FLACS cases, with an increased risk of complications, including incomplete capsulotomy 90,91 . However, stabilization of complication rates was observed after 200 FLACS cases 90,91 …”

“…Other studies also showed the presence of a steep learning curve in the initial 100 to 200 FLACS cases, with an increased risk of complications, including incomplete capsulotomy 90,91 . However, stabilization of complication rates was observed after 200 FLACS cases 90,91 …”

“…[1][2][3] Previous studies have indicated that a significant learning curve is required for the FLACS technique. 28,89,90 In particular, poor docking between the eye and laser platform can occur during the initial phase of the learning curve, resulting in lens tilt, incomplete capsulotomy, microadhesions, and incomplete lens fragmentation. 28,89 However, these complications rapidly decreased after the completion of the learning curve.…”