When, 260 years ago, Jacques Daviel stated his aim “…to entirely loosen the cataract and facilitate its issue,” he probably had a technique in mind that enabled the surgeon to operate fast, with short, precise cuts and with a high degree of safety and postoperative vision for his patients. Modern cataract surgery—which is almost always refractive surgery as well—has come closer to perfection than this pioneer in our field (who lived from 1696 until 1762) could have ever imagined. In fact, cataract surgeons in this day and age are in a position envied by colleagues in most other medical disciplines: not only will the organ in the cataract surgeon’s crosshairs enjoy a better function than preoperatively—in some cases (one might think of an almost lifelong myopia that is corrected by an IOL) it might work better than ever before in the patient’s life, without refractive error, astigmatism, and, of course, lens opacity.

The introduction of the femtosecond laser into cataract surgery, after its successful debut in refractive surgery, is part of this success story—and gives reason to expect further progress and unequaled patient satisfaction, particularly in patients with premium IOL implantation. A variety of femtosecond laser platforms have been introduced into cataract surgery, among those approved by the FDA are LensAR (LensAR Inc, Winter Park, FL), LenSx (Alcon LenSx Inc, Fort Worth, TX), Catalys (Abbott Medical Optics, Abbott Paark, Illinois, USA) and Victus (Bauch & Lomb/Technolas Perfect Vision GmbH, Munich, Germany) [1].

Our research in the field of femtosecond laser-assisted cataract surgery is based on our clinical experience with the Catalys system. Unique to that platform is a liquid optics interface docking system that includes a fluid-filled suction ring and a non-applanating disposable lens (Fig. 12.1). This docking system is engaged by the surgeon while he or she controls the patient’s chair using video imaging for alignment. Once suction is confirmed, the system automatically measures the dimensions of the anterior chamber and the lens with an integrated three-dimensional spectral-domain optical coherence tomography device. This SD-OCT identifies the ocular surfaces and creates laser exclusion zones (Fig. 12.2). The results are displayed to the surgeon for verification. At this point, the surgeon has the option of using the videographic user interface to reposition and/or redesign the corneal incisions, the capsulotomy, and lens fragmentation procedures. The advantages of the non-applanating Liquid Optic interface are a relatively mild rise in intraocular pressure (see below), a better optical quality for the surgeon, almost no corneal folds (Fig. 12.3), and fewer cosmetically challenging complications like subconjunctival hemorrhages—there is hardly any sign of ocular discomfort like redness in most eyes even on the day of surgery.

The attempted capsulotomy diameter usually is 5.0 mm (4 μJ pulse energy). The lens-softening pattern applied by the femtosecond laser is standardized; the grid size is normally either 350 or 500 μm (Fig. 12.4). The femtosecond laser pulses are focused starting at the predefined distance from the posterior capsule (posterior safety margin) and moved in the anterior direction through the crystalline lens (Table 12.1 and Fig. 12.2). The laser does not create planes across the lens in the coronal plane. The gas released from cavitation bubbles creates a pneumodissection effect that further separates the crystalline lens along the natural lamellar structure, reducing the need for hydrodissection and most often creating cubes of softened lens. However, the laser itself does not cut cubes but rather slices the lens.

Ultrasound phacoemulsification is performed in our clinic on the same operating chair, without moving or walking the patient through the operating room. Preparing the patient for phacoemulsification and IOL implantation with the femtosecond laser results in a considerable reduction of effective phacoemulsification time. In two groups of 80 patients each, one group receiving a 350 μm grid pattern and the other a 500 μm grid pattern, the mean absolute phacoemulsification time was 0.03 and 0.21 s, respectively. Cataract surgeons have for almost two decades evaluated ways to reduce the amount of ultrasound energy the ocular structures are exposed to. The femtosecond laser has achieved this goal most convincingly. There is a plethora of benefits for the patient: less energy delivered to the eye may be associated with an earlier improvement in postoperative visual acuity as a result of less endothelial cell loss and corneal edema and less anterior chamber cells and flare caused by alteration of the blood–aqueous barrier. The corneal swelling in the early postoperative period is less pronounced after femtosecond laser application than after conventional phacoemulsification; Takacs et al. described a significantly higher central corneal thickness after phacoemulsification alone (607 μm on average) than after pretreatment with the femtosecond laser (580 μm) in groups of 38 eyes each [2]. Less phacoemulsification energy usually means a faster and safer visual rehabilitation after cataract surgery [3].