ARTICLE

Intraocular pressure variation during

femtosecond laserassisted cataract surgery
using a fluid-filled interface
Tim Schultz, MD, Ina Conrad-Hengerer, MD, Fritz H. Hengerer, MD, H. Burkhard Dick, MD

PURPOSE: To evaluate intraocular pressure (IOP) during femtosecond laserassisted cataract surgery using a fluid-filled interface.
SETTING: Ruhr University Eye Clinic, Bochum, Germany.
DESIGN: Prospective clinical trial.
METHODS: The absolute IOP was measured with a modified Schiotz tonometer before and after
laser-assisted cataract surgery with and without a fluid-filled interface (Liquid Optics interface,
Catalys Precision Laser System).
RESULTS: The study evaluated 100 eyes. Tonometry and laser cataract surgery were completed
successfully in all eyes. The mean preoperative IOP was 15.6 mm Hg G 2.5 (SD). Upon application
of the suction ring and vacuum, the mean IOP rose to 25.9 G 5.0 mm Hg and remained nearly constant after the laser procedure (27.6 G 5.5 mm Hg). After removal of the suction ring, the mean IOP
was 19.1 G 4.4 mm Hg. The IOP 1 hour after surgery was not significantly higher than the preoperative values.
CONCLUSIONS: The results indicate a minor increase in IOP using the fluid-filled interface. This is in
strong contrast to substantially higher values reported in the literature with flat and curved
applanating contact interfaces.
Financial Disclosure: Dr. Dick is a member of the Medical Advisory Board and a paid consultant to
Optimedica, Sunnyvale, California, USA. No other author has a financial or proprietary interest in any
material or method mentioned.
J Cataract Refract Surg 2013; 39:2227 Q 2013 ASCRS and ESCRS

Manual capsulorhexis and ultrasound phacoemulsification are the current treatment standard for cataract
surgery.1,2 The introduction of femtosecond lasers for
cataract surgery shows great promise in increasing
the accuracy and precision of the cuts compared
with manual treatment.3 With this tool, future clinical
studies should show improved patient safety profiles
and refractive outcomes.38
Submitted: June 3, 2012.
Final revision submitted: October 5, 2012.
Accepted: October 11, 2012.
From the Center for Vision Science, Ruhr University Eye Clinic,
Bochum, Germany.
Corresponding author: Tim Schultz, MD, Center of Vision Science,
Ruhr University Eye Hospital, In der Schornau 23-25, 44892
Bochum, Germany. E-mail: tim.schultz@kk-bochum.de.

22

Q 2013 ASCRS and ESCRS

Published by Elsevier Inc.

Like laser in situ keratomileusis (LASIK) ablation laser systems, all ophthalmic femtosecond laser systems
use a patient interface to directly contact the patients
eye to maintain mechanical stability between the optical laser system and the patient and to allow a welldefined optical interface. In addition, the interfaces
are used to register the ocular target and the laser focal
position to ensure that the incision is in the correct
location.
A flat applanating contact lens was introduced with
the first femtosecond laser (Intralase, Abbott Medical
Optics, Inc.) for flap creation. This interface proved
to be reliable and is still in use today despite very
high intraocular pressure (IOP) resulting from corneal
compression during the applanation process. Various
studies911 have evaluated IOP changes in in vivo or
ex vivo animal models. The reported mean maximum
IOP in enucleated porcine globes during the regular
0886-3350/$ - see front matter
http://dx.doi.org/10.1016/j.jcrs.2012.10.038

IOP DURING LASER-ASSISTED CATARACT SURGERY USING A FLUID-FILLED INTERFACE

procedure was 134 mm Hg G 16 (SD) when the Intralase device was used and 184 G 28 mm Hg when the
Femto LDV device (Ziemer Ophthalmic Systems AG)
was used.11
To reduce these IOP peaks, other femtosecond flap
laser systems use a curved applanation interface in
which the interface has some amount of curvature to
better fit the natural corneal curvature; this limits the
IOP rise during applanation. Reported mean maximum IOPs during the regular procedure using the
curved applanation interface with porcine globes
were between 65 G 20 mm Hg (Visumax, Carl Zeiss
Meditec AG) and 205 G 32 mm Hg (Femtec, Technolas
Perfect Vision GmbH).11 Similar data were shown in
the few available in vivo human studies.12
With laser-assisted cataract surgery, significantly
older patients are exposed to IOP increases for several
minutes during treatment. These individuals are at
higher risk for complications than relatively young
and healthy refractive LASIK surgery patients. In the
United States, up to 39% of the people older than
65 years are under permanent anticoagulation with
aspirin and optic nerve perfusion is lower.13,14
Furthermore, the incidence of chronic open-angle
glaucoma and ocular hypertension, as well as retinal
occlusive disease, increases with age.15,16 It has been
reported that the use of traditional laser system
patient interfaces may increase the risk for subconjunctival hemorrhage,17 retinal detachment,18 optic neuropathy,19 macular holes,20 and foveal hemorrhage.21
For some time, ultrasonic examination devices have
used water immersion to minimize the impedance
mismatch between the transducer and the eye.22
With this technique, no pressure is applied to the cornea because there is no direct force or deformation of
the corneal structure. Only the sealing interface is in
direct contact with the sclera.
Currently available femtosecond laser cataract surgery systems use a curved applanation patient interface (Lensx Laser System, Lensx; Victus, Technolas
Perfect Vision GmbH) or a fluid-filled interface
(Catalys Precision Laser, Optimedica; Lensar Laser
System, Lensar, Inc.).23 Similar to the ultrasonic immersion interfaces, the fluid-filled interfaces for the
laser systems overcome the optical refraction of the
cornea while avoiding the corneal deformation and
associated IOP rise. Such a configuration should
substantially limit the IOP increase, as is appropriate
for the cataract surgery patient population. The only
possible cause of an IOP rise might be induced by
the water-sealing interface or suction ring that is applied to the eye. Proper design of this suction ring
should greatly minimize, if not avoid, the IOP rise.
In addition, the fluid-filled interface avoids the folds
in the corneal posterior surface associated with

23

hard-curved patient interfaces.A Because previously

applanation tonometry was not possible during femtosecond laser surgery, studies912 used direct cannulation of the anterior chamber or vitreous body to
measure the IOP. The fluid-filled interface provides access to the cornea and offers the possibility of atraumatic examinations.
It has been reported that Schiotz tonometers measure different IOP than Goldmann-type tonometers,
with the results reported as higher and as lower.2426
As such, a range of Schiotz-measured pressures is
generally reported rather than a single value. We acknowledge this but chose to use the Schiotz tonometer
because it readily fits within the small inner volume of
the interface and is oriented for use with supine
patients. The preoperative measurements using both
Goldmann and Schiotz tonometers agreed well.
The aim of this prospective clinical trial was to quantify the absolute IOP variation during femtosecond laserassisted cataract surgery using the Catalys Liquid
Optics Interface.
PATIENTS AND METHODS
This study comprised patients scheduled for elective femtosecond laserassisted cataract surgery and implantation of
an intraocular lens (IOL) by 1 of 2 trained surgeons
(H.B.D., F.H.) at the Center for Vision Science, Ruhr University Eye Clinic, Bochum, Germany. The study received institutional review board approval of the Ethics Committee,
Ruhr University, and all aspects of the Declaration of Helsinki were observed.
Patients were eligible for the study if they had significant
cataract, were older than 21 years, and understood and
signed an informed consent document. Excluded were patients with mature cataracts, angle-closure or uncontrolled
glaucoma, active inflammation in the eye, a history of corneal surgery, opacities or corneal disease, central corneal
thickness less than 500 mm or greater than 600 mm, active
iris neovascularization, presence of intraocular silicone oil,
ocular or systemic steroid use within 3 months before the
preoperative visit, participation in another drug or device
clinical trial concluding within 30 days of the preoperative
visit, unsuitable for local anesthesia, known or suspected allergy to drugs required for the protocol, or who were pregnant or nursing.

Laser System and Patient Interface Docking

All laser surgery was performed with the Catalys Precision Laser System, which has been described in detail.27
After patient docking, the system automatically detects the
cornea and lens surfaces using optical coherence tomography (OCT) and creates a 3-dimensional (3-D) treatment
plan for each patient.
The Catalys patient interface is composed of 2 parts: a suction ring that contacts only the sclera (outer diameter
18.0 mm) and a disposable lens that rigidly mates the suction
ring to the surgical system. In the first step, the suction ring
(Figure 1, B) is placed centrally on the sclera of the eye
(Figure 1, A). After fine adjustments, the suction ring vacuum is enabled, which connects the suction ring to the

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IOP DURING LASER-ASSISTED CATARACT SURGERY USING A FLUID-FILLED INTERFACE

Table 1. Study time points and IOP measurement device used.

Study Time Point
Preoperative
Before suction
With suction
After femto with suction
After femto without suction
1 hour postoperative

Device Used
Goldmann tonometer
Schiotz tonometer
Schiotz tonometer
Schiotz tonometer
Schiotz tonometer
Goldmann tonometer

1 hour postoperative Z IOP measured 1 hour after surgery on sitting patients; After femto with suction Z IOP measured after laser procedure
with suction ring in place and with applied vacuum on lying patients; After femto without suction Z IOP measured 1 minute after vacuum turned
off and suction ring removed on lying patients; Before suction Z IOP
measured before laser treatment on lying patients; Preoperative Z IOP
measured 2 days before surgery on sitting patients; With suction Z IOP
measured after applying vacuum to suction ring on lying patients

Surgical Technique

Figure 1. Schematic of the docking process (A Z eye; B Z suction

ring; C Z disposable lens; 1 Z docking between suction ring and
eye; 2 Z docking between disposable lens and suction ring).

patients eye. Second, the suction ring volume is filled with

a balanced salt solution (BSS, Alcon). In the final step, the
filled suction ring is adjusted and connected to the disposable lens (Figure 1, C). Excess fluid is free to discharge
from any of 3 openings near the top of the suction-ring
housing.

Femtosecond laserassisted cataract surgery was performed in 1 eye of each patient. After pupil dilation (phenylephrine 2.5% and tropicamide 0.5%) and corneal anesthesia
(oxybuprocaine hydrochloride, Conjucain EDO 0.4%,
Bausch & Lomb), all patients were placed in a supine position in the operating chair. No eye speculum was used. After
the patient was docked to the system, the OCT imaged the
anterior chamber and the system created a 3-D treatment
plan. In all cases, the laser created a 5.0 mm diameter curvilinear capsulotomy (4 mJ pulse energy). The lens was segmented into quadrants and softened with grid spacing of
350 mm (10 mJ pulse energy).
All patients remained in the same operating chair during
the entire procedure. The manual surgical cataract procedure
was performed directly after laser treatment and measurements. The Stellaris phacoemulsification device (Bausch &
Lomb) was used for nuclear disassembly.

Statistical Analysis

Intraocular Pressure Measurements

Intraocular pressure values, patient age, and total suction

time were calculated using the mean G SD. The significance
of IOP changes was calculated using the t test. A P value less
than 0.05 was considered statistically significant. All calculations were performed using SPSS Statistics for Windows
software (version 19.0, SPSS, Inc.).

Pretreatment and posttreatment IOPs were measured using a Goldmann tonometer. The results were adjusted to the
corneal thickness with the Dresdner chart.28 All other readings were performed using a modified Schiotz tonometer.
The handles of a Schiotz tonometer were bent upward to enable pressure readings even with the suction ring applied to
the patients eye. Before every application, the Schiotz tonometer was cleaned by submersion in sodium hypochlorite
2% solution and the calibration was checked with the manufacturers calibration sphere. For all measurements, the 7.5 g
weight was used.29 The laser procedure and pressure readings were performed by the same surgeon (H.B.D. or F.H.).
Pressure readings were taken as shown in Table 1. Directly
after surgery, patients were asked whether they had vision
problems during the procedure; for example, whether amaurosis occurred.

RESULTS
The study group consisted of 51 men and 49 women
with a mean age of 70 G 12 years (range 28 and 91
years).
Table 2 and Figure 2 show the mean measured IOPs.
No significant difference was found between baseline
IOP 2 days before treatment and the IOP right before
suction ring application (PZ1.0). After the vacuum
was applied to engage the suction ring to the patients
eye, the IOP significantly increased by a mean of
10.3 mm Hg (P!.001). Laser-assisted cataract treatments were successfully performed in all cases. No

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IOP DURING LASER-ASSISTED CATARACT SURGERY USING A FLUID-FILLED INTERFACE

Table 2. Mean IOP data at the different study time points and
their statistical significance.

Study Time Point

Mean (mm
Hg) G SD

Range

P Value

Preoperative
Before suction
With suction
After femto with suction
After femto without suction
1 hour postoperative

15.6 G 3.4
15.6 G 2.5
25.9 G 5.0
27.7 G 5.5
19.1 G 4.4
14.3 G 4.4

8.0, 23.0
9.0, 21.9
17.0, 38.8
15.6, 38.8
9.0, 30.4
8.0, 26.0

1.000
!.001
!.001
!.001
!.001

1 hour postoperative Z IOP measured 1 hour after surgery on sitting patients; After femto with suction Z IOP measured after laser procedure
with suction ring in place and with applied vacuum on lying patients; After femto without suction Z IOP measured 1 minute after vacuum turned
off and suction ring removed on lying patients; Before suction Z IOP
measured before laser treatment on lying patients; Preoperative Z IOP
measured 2 days before surgery on sitting patients; With suction Z IOP
measured after applying vacuum to suction ring on lying patients

patients had suction loss during the laser treatment,

and no adverse events occurred. Furthermore, no patient reported amaurosis. Immediately after laser
treatment, with suction ring still applied, the IOP
increased significantly (P!.001). After removal of
the suction ring, the IOP decreased significantly. The
mean total suction time was 3:45 G 1:21 minutes.
Standard cataract surgery and IOL implantation was
performed in all cases. The IOP was back to initial

Figure 2. Intraocular pressure measured at different time points during the cataract treatment (1 hour postoperative Z IOP measured
1 hour after surgery on sitting patients; after femto with suction Z
IOP measured after laser procedure with suction ring in place and
with applied vacuum on lying patients; after femto without suction
Z IOP measured 1 minute after vacuum turned off and suction ring
removed on lying patients; before suction Z IOP measured before
laser treatment on lying patients; preoperative Z IOP measured
2 days before surgery on sitting patients; with suction Z IOP measured after applying vacuum to suction ring on lying patients).

25

levels 1 hour after surgery, but not higher than the pretreatment level (PZ.038).
DISCUSSION
The measurements showed an increase in IOP resulting from the use of the suction ring. A second rise in
IOP was induced by the femtosecond laser treatment.
In all cases, the highest recorded pressure did not exceed 38.8 mm Hg and the IOP returned to a normal
level after the suction ring was removed.
To our knowledge, no other study has analyzed the
IOP variations in vivo during femtosecond laserassisted cataract surgery with a fluid-filled interface. The
only available data are results that assessed the
changes in IOP in porcine and human cadaver eyes after suction. These findings indicated a mean increase
in IOP in porcine eyes of 17.7 G 2.1 mm Hg and of
3.8 mm Hg lower in human cadaver eyes.B
No additional IOP increase is expected from the
weight or pressure of the balanced salt solution added
to the suction ring because excessive balanced salt solution can vent through the opening in the suction ring
when it is displaced by the lens during docking. Nevertheless, lateral force during the docking process might
induce an additional IOP rise that was not measured.
In all patients, the IOP will rise during the docking
process when the suction ring mates with the disposable lens. Because the cornea is fully enclosed by the laser system, no pressure reading could be taken at this
step of the procedure. The suction ring will be forced
downward by the additional weight of the disposable
lens, raising the IOP by pressing the suction ring
against the patients eye until the lens is locked and
the weight is removed. In addition, strong forces
against the suction on the eye from patient movements
might further increase the IOP under suction. The system monitors lateral and vertical forces continually
during docking and treatment and provides feedback
to the surgeon to minimize them. It will automatically
stop treatment and release the suction and the patient
when the force applied exceeds a safety threshold. Beyond that, the absence of amaurosis indirectly confirms a limited additional IOP rise.
Results of IOP measurements during femtosecond
laserassisted cataract surgery with an applanating
or direct curved lens model are also not available.
The only published data report a negligible pressure
increase 2 weeks and 4 weeks after surgery.30
Several previous studies analyzed IOP variations
during corneal flap creation with a femtosecond laser
using flat and curved contact lenses. As described, in
experimental setups with enucleated porcine globes,
the maximum mean IOP with flat and curved lenses
was 65 G 20 mm Hg (Visumax), 135 G 16 mm Hg

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IOP DURING LASER-ASSISTED CATARACT SURGERY USING A FLUID-FILLED INTERFACE

(Intralase), 205 G 32 mm Hg (Femtec), and 184 G

28 mm Hg (Femto LDV).11 In contrast, the fluidfilled suction device used in this study led to a significantly lower IOP increase, which might in turn lead to
a lower complication rate.
The pressure increase immediately after the laser
treatments may be traced to volume changes created
by the gas development in the lens during laser treatment. Because gas leakage from the lens and into the
anterior chamber has been observed and because of
the relatively low increase in IOP, it is to be expected
that no great damage will occur to the eye when this
fluid-filled interface is used.
In addition, the fluid-filled interface used in this
study provides an unaltered view of the anterior eye
out past the limbus while limiting conjunctival hemorrhage. The limbal suction has been shown not to
produce corneal folds, such as may occur when
corneal-contact patient interfaces are used.B
In conclusion, the fluid interface opens the possibility of treating older cataract patients with a femtosecond laser with a minimal increase in IOP. The
combination of low IOP and minimal anatomic
changes during the treatment might lead to fewer
complications and a better visual outcome. Unlike
most refractive surgery patients, those with cataract
typically present with accompanying conditions,
such as elevated IOP and various retinopathies.
Raising the IOP may iatrogenically compromise these
patients with multiple morbidities. More studies are
needed to quantify improvements in vision and
changes in the rate of complications.
WHAT WAS KNOWN
 Flat and curved applanating patient interfaces can cause
high IOP during femtosecond laser surgery, such as in
LASIK flap cutting.
WHAT THIS PAPER ADDS
 The fluid-filled interface showed a considerably lower
increase in IOP, which makes it safer to use for cataract
patients.

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J CATARACT REFRACT SURG - VOL 39, JANUARY 2013

First author:
Tim Schultz, MD
Center for Vision Science, Ruhr
University Eye Clinic, Bochum,
Germany