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PERSPECTIVE

Femtosecond Lasers in Ophthalmology


H. KAZ SOONG AND JOO BAPTISTA MALTA To provide an update and review of femtosecond (FS) lasers in clinical ophthalmology. DESIGN: Perspective, literature review, and commentary. METHODS: Selected articles from the literature and the authors clinical and laboratory studies. RESULTS: The FS laser employs near-infrared pulses to cut tissue with minimal collateral tissue damage. Although its major use at present is in the cutting of laser in situ keratomileusis aps, the laser has proven its versatility in laser-assisted anterior and posterior lamellar keratoplasty, cutting of donor buttons in endothelial keratoplasty, customized trephination in penetrating keratoplasty, tunnel creation for intracorneal ring segments, astigmatic keratotomy, and corneal biopsy. Current laboratory studies include allFS laser refractive keratomileusis sans ap, cutting corneal pockets for insertion of biopolymer keratoprostheses, noninvasive transscleral glaucoma surgery, retinal imaging and photodisruption, presbyopia surgery, and anterior lens capsulorrhexis. CONCLUSIONS: Advances in ultra-fast laser technology continue to improve the surgical safety, efciency, speed, and versatility of FS lasers in ophthalmology. (Am J Ophthalmol 2009;147:189 197. 2009 by Elsevier Inc. All rights reserved.)
PURPOSE:

NEAR-INFRARED LASERS IN OPHTHALMOLOGY


THE OPTICALLY TRANSPARENT REFRACTIVE LAYERS OF THE

HE DEVELOPMENT OF THE RUBY LASER ALMOST A

half-century ago by T. H. Maiman was an epiphany that opened up wide new vistas in ophthalmology, resulting in a ood of practical clinical applications of lasers in eye surgery.1 The development of clinical argon, krypton, carbon dioxide, neodymium-doped yttrium aluminum garnet (Nd:YAG), and excimer laser systems in ophthalmology made it possible to treat a wide array of eye diseases and disorders (Table).

Accepted for publication Aug 19, 2008. From the Department of Ophthalmology and Visual Sciences (H.K.S., J.B.M.), W. K. Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan; and the Department of Ophthalmology (J.B.M.), Division of Cornea and External Disease, Santa Casa de So Paulo, So Paulo, Brazil. Inquiries to H. Kaz Soong, W. K. Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI 48105; e-mail: hksoong@umich.edu
0002-9394/09/$36.00 doi:10.1016/j.ajo.2008.08.026

eye, such as the cornea and lens, do not absorb electromagnetic radiation in the visible or near-infrared spectrum at low power densities, allowing light to pass through without alteration of these tissues. At higher power densities, however, these structures do absorb the light energy, leading to plasma generation and tissue disruption. The rst practical use of near-infrared lasers in clinical ophthalmology was the focused Nd:YAG laser, widely used for opening of opacied posterior lens capsules after cataract surgery, iridotomy in pupillary-block glaucoma, and less commonly, lysis of vitreous membranes or tags. The Nd:YAG laser has a pulse duration in the nanosecond (10 9 second) range and produces photodisruption at its focal point in tissue, resulting in a rapidly expanding cloud of free electrons and ionized molecules (plasma), in turn creating an acoustic shock wave that disrupts the treated tissue. This process, also known as photoionization or laser-induced optical breakdown, vaporizes small volumes of tissue with the formation of cavitation gas bubbles consisting of carbon dioxide and water, which eventually dissipate into the surrounding tissues.2 The zone of collateral tissue damage with the nanosecond Nd:YAG laser may easily exceed 100 m, as illustrated by frequent damage to posterior-chamber intraocular lenses during Nd:YAG laser posterior capsulotomy. This large volume of collateral damage renders this laser impractical for use in corneal surgery, which demands much higher precision. By shortening the pulse duration of the near-infrared laser from the nanosecond to the picosecond (10 12 second) domain and then to the femtosecond (10 15 second) domain, the zone of collateral tissue damage is progressively reduced. The femtosecond (FS) laser is similar to a Nd:YAG laser, but with an ultra-short pulse duration that is capable of producing smaller shock waves and cavitation bubbles that affect a tissue volume about 103 times less than picosecond-duration pulses.3 The prototype of the rst ophthalmic surgical FS laser system was designed and constructed by Dr Juhasz and his associates at the University of Michigan College of Engineering Center for Ultra-fast Optical Sciences (CUOS) in the early 1990s through a $14.3 million endowment from the National Science Foundation and the state of MichiRIGHTS RESERVED.

2009 BY

ELSEVIER INC. ALL

189

TABLE. Lasers in Ophthalmology


Laser Wavelength (nm) Effect in Tissue

Carbon dioxide Nd:YAG Femtosecond Krypton Argon Excimer Nd:YAG

10 600 (far infrared) 1064 (near infrared) 1053 (near infrared) (647531 visible light) (514488 visible light) (193 far ultraviolet)

Photothermal Photodisruption Photodisruption Photochemical (coagulation) Photochemical (coagulation) Photoablation

neodymium-doped yttrium aluminum garnet.

gan. The design, development, and analyses of clinical laser parameters for use in corneal surgery were done in collaboration with Dr Kurtz and associates from the W. K. Kellogg Eye Center, University of Michigan Medical School. The IntraLase Corporation was founded in 1997 in Michigan and included several members of this original research team. The CUOS ultra-short duration laser prototype was based on creation of pulses with a solid-state Nd:YAG laser, which undergo chirped pulse amplication, a technique developed by Dr Gerard Mourou, then professor of electrical engineering and director of CUOS. Laser pulses are stretched in duration from 200 femtoseconds to 50 picoseconds, amplied, and recompressed to 500 femtoseconds, whereupon they are delivered at a repetition rate of 1 to 10 kHz via a complex system of mirrors.4 As laser power is dened as energy delivered per unit time (P E/ ), decreasing the pulse duration not only increases the delivered power without increasing the energy, but also decreases the uence (energy per unit area) threshold for laser-induced optical breakdown. In turn, the high peak intensity of the FS laser translates into smaller cavitation bubble size (microcavitation) and less collateral tissue damage than nanosecond or picosecond lasers.5 The nearinfrared FS laser can be focused anywhere within or behind the cornea, unlike the unfocused, far-ultraviolet excimer laser, which is absorbed at the anterior surface of the cornea. To a limited degree, the FS laser is also capable of passing through optically hazy media such as edematous cornea and even the relatively translucent perilimbal sclera, because its infrared-wavelength energy undergoes much less attenuation than visible light. The IntraLase clinical FS laser is scanned over the target tissue with a high-precision, computer-controlled optical delivery system, achieving an accuracy of approximately 1 m6 and allowing contiguous placement of laser pulses in either raster (zigzag) or expanding (centrifugal) spiral patterns (Figure 1). The IntraLase Pulsion FS laser was approved for use by the U.S. Food and Drug Administra190 AMERICAN JOURNAL
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tion (FDA) for lamellar corneal surgery in January 2000 and the rst commercial laser was introduced to the market in 2001 for use in producing laser in situ keratomileusis (LASIK) aps. Unlike mechanical microkeratomes, no blades or moving parts are used in the LASIK ap-cutting process. Although rst introduced as a 10-kHz laser in 2002, the current IntraLase system res at a pulse rate of 60 kHz, allowing for shorter ap-cutting times, less energy to cut the ap, and closer separation of the spots and lines. In the new 150-kHz fth-generation IntraLase FS system, with its high-precision computer control of the parameters, the delivery system can create cuts of a wide variety of geometric shapes, depths, diameters, wound congurations, energy, spot sizes, and spot separation. It is capable of creating LASIK aps in less than 10 seconds. The IntraLase system employs a low-pressure (35 to 45 mm Hg) suction ring with a at applanating glass contact lens to align and stabilize the globe, to act as an eyelid speculum, and to atten the cornea to a physically simpler planar shape. This pressure is lower than that used in mechanical microkeratomes and may, therefore, possibly reduce the risk of retinovascular occlusion and neural infarction. For LASIK aps, the lamellar interface cut is connected to the corneal surface with vertical side cuts with a hinge of desired arc and meridian (Figures 1 and 2). For anterior lamellar keratoplasty (ALKP), the ap hinge option is turned off to create an intentional free cap of anterior corneal button. The laser parameters may also be controlled to produce: 1) penetrating keratoplasty (PKP) cuts with shaped graft-host junctions, consisting of complex, interlocking wound congurations; 2) posterior donor lamellar buttons in deep lamellar endothelial keratoplasty (DLEK) and Descemet stripping with automated endothelial keratoplasty (DSAEK) surgery; 3) tunnels for intracorneal ring (INTACS) insertion; 4) aps for corneal lenticular inlays; 5) arcuate astigmatic keratotomy incisions; and 6) cuts in recipient corneas for permanent keratoprosthesis implantation. Recently, three newer U.S. FDAapproved FS laser systems have entered the American market: 1) the Femtec (20/10 Perfect Vision, Heidelberg, Germany); 2) the Femto LDV (previously Da Vinci, Ziemer Ophthalmic Systems, Port, Switzerland); and 3) the VisuMax (Carl Zeiss Meditec AG, Jena, Germany). The Femtec laser employs a curved applanating lens, requiring less suction pressure during treatment. Corneal lamellar cuts are made parallel to the curvature of the applanating lens and in a centripetal spiral pattern (Figure 1, Right), allowing the opaque bubble layer, formed by the cavitation gas, to stay in the periphery of the cut. Loss of suction during the cutting process may not be as critical as in the at lens systems, since the cornea is less forcibly distorted during the applanation process. The VisuMax, like the Femtec, employs a curved applanating lens. The Femto LDV operates in the mHZ ring rate range, rather than kHz, allowing for reduced ap-making time and possible imOPHTHALMOLOGY FEBRUARY 2009

FIGURE 1. (Top) Cross-sectional schematic diagram of laser in situ keratomileusis (LASIK) ap cut with contiguous laser spot placement for side cut and lamellar (interface) creation. (Bottom) LASIK ap cut using raster pattern (left), centrifugal spiral pattern (center), and centripetal spiral pattern (right).

FIGURE 2. (Left) Schematic diagram of LASIK ap creation with raster pattern, while cornea is attened by applanating lens. (Right) Flap after lifting.

provement in smoothness and precision with the use of more numerous, lower-energy, tightly arranged, smaller spots. It employs a exible mirror arm and has a compact setup. The compact setup, however, may limit the systems versatility in cutting geometry to a certain degree.7 VOL. 147, NO. 2

Femtosecond laser systems have strict ambient humidity and temperature requirements for proper operation, but advances in FS laser technology are making the newer machines less sensitive to environmental perturbations. FS lasers are also rapidly gaining popularity in 191

FEMTOSECOND LASERS

FIGURE 3. Opaque bubble layer [OBL] (arrow) during LASIK ap creation.

many other elds of medicine, such as in dentistry and neurosurgery.

FEMTOSECOND LASER IN SITU KERATOMILEUSIS FLAPS


AT PRESENT, CORNEAL FLAP CREATION IN LASIK SURGERY

is the most common application of the FS laser. Since its introduction to the market in 2002, its use has steadily burgeoned and a poll taken in 20068 indicated that over 30% of all LASIK aps were made with the FS laser, under such monikers as IntraLASIK, all-laser LASIK, and bladeless LASIK. The FS laser pulses are red in a raster or spiral pattern at a predetermined depth in the corneal stroma to create the lamellar cut and then in a peripheral circular pattern (going in the posteroanterior direction) to create the vertical side cuts (Figure 1). Remaining adherent stromal bridges across the ap interface are easily lysed with a gentle sweep of an instrument, such as the Barraquer iris sweep. With the availability of increasingly fast ring rates with recent technological advances, the sweeping and lifting of the ap become easier as a result of smaller spot sizes and tighter spot separation. The vertical side cuts reduce side slippage of the LASIK ap and also facilitate precise placement of the ap back into its original position, somewhat akin to a well-tting manhole cover. The major advantages of FS laser ap creation over the mechanical microkeratome are: 1) reduced incidence of ap complications, such as buttonholes, epithelial abrasions, short aps, free caps, blade marks, and irregular cuts;9,10 2) greater surgeon choice of ap diameter and 192 AMERICAN JOURNAL
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thickness, side cut angle, hinge position and length, spot size and separation, and ring patterns (spiral vs raster); 3) absence of moving parts; 4) increased precision with improved ap safety and thickness predictability;9,10 and 5) capability of cutting thinner aps (90 m or even less) to accommodate thin corneas and/or high refractive errors. On the other hand, its high price, large physical size, and lack of portability preclude the FS laser from completely superseding the mechanical microkeratome. Recent mechanical microkeratome systems, such as the Amadeus II (Ziemer Ophthalmic Systems, AG) and the CarriazoPendular (Schwind Eye-tech Solutions, Kleinostheim, Germany), have greatly improved cutting precision and are able to create thin aps that may rival that of the FS laser (Holzer MP. Current aspects: Corneal surgery with the Femtec laser. Cataract & Refractive Surgery Today Europe. Available at: http://www.crstodayeurope.com/ Issues/0407/0407_f6_holzer.html). The higher 60-kHz laser ring speeds have reduced the energy requirements, thus reducing the cavitation bubble size and duration, tissue inammation, time of ap creation, and ease of ap lifting. The Femto LDV and the new fth-generation IntraLase FS laser have recently achieved even faster ring speeds of mHz domain and 150 kHz, respectively. Conuent cavitation bubbles during intrastromal treatment (opaque bubble layer [OBL]) (Figure 3) may confound the ability of the surgeon and the excimer laser eye tracker device to locate the pupil for centration purposes. The duration and area of OBL are reduced by use of the raster or centripetal spiral patterns, peripheral gutters programmed into the cut which divert the OBL away from the center, and the lesser energy levels needed with faster ring speeds. The faster ring speeds also allow the leading edge of treatment to stay ahead of the spreading OBL. With the rapid pulse delivery, the time required for laser ap creation now rivals that of the mechanical microkeratomes. Femtosecond LASIK complications are rare, but include unique problems, such as interference of surgery by cavitation gas bubbles during treatment and the transient light-sensitivity syndrome (TLSS) after surgery. Gas bubbles routinely accumulate in the ap interface during FS laser treatment, but occasionally they may dissect into the deep stromal bed, resulting in posterior stromal OBL that does not escape when the ap is lifted (Figure 4), persisting for hours before reabsorption. If it is central and dense, the OBL may severely hamper iris registration and pupil localization by the eye tracker. In rare instances, bubbles may escape into the corneal subepithelial space (Figure 4) without lasting adverse consequences, but larger central vertical gas breakthrough may potentially result in a ap buttonhole.11 Anteriorly dissected gas bubbles may also be trapped between the applanating lens and the corneal surface, obstructing subsequent laser spots to the area. A major risk factor for this complication is previous incisional corneal surgery, such as keratotomy and keratoOPHTHALMOLOGY FEBRUARY 2009

FIGURE 4. Cavitation gas may occasionally enter posterior stroma, subepithelial space, and anterior chamber (AC).

plasty. This may, in turn, lead to the retention of thick stromal bridges across the interface. In such an event, it is advisable to not forcefully lift the ap, but to instead recut the cornea at a different depth after several weeks of healing. Seepage of the intrastromal gas bubbles into the anterior chamber (AC) is extremely rare and is thought to be caused by peripheral dissection of the intrastromal gas through the trabecular meshwork and into the AC (Figure 4).12 Although the bubble is reabsorbed over a period of hours, its presence in the AC hinders the eye tracker device from centering the excimer laser beam over the pupil, thus forcing the surgeon to either manually center the ablative treatment or alternatively to delay lifting the ap until the bubbles disappear. Transient light-sensitivity syndrome usually occurs days to weeks after FS laser LASIK and is characterized by extreme photophobia with good visual acuity and absence of clinical ndings on examination. It resolves without residual sequelae after a few weeks of treatment with an aggressive course of topical corticosteroids.13 Although the exact mechanism is unknown, it is believed to be either a biochemical response of the keratocytes to the nearinfrared laser energy or an inammatory response of the surrounding tissue to the gas bubbles. Diffuse lamellar keratitis (DLK) in the ap interface was relatively common in the earlier FS laser surgeries,14 but it has become much less frequent with the advent of the faster ring systems. Mild transient lamellar keratitis limited to the periphery is still encountered occasionally, perhaps causally related to the higher energies used for making the vertical side cuts. This lamellar inammation appears to be distinct from DLK seen in LASIK performed with the mechanical microkeratome and it is likely attributable to photodisruption-induced microscopic tissue injury, aggravated by ocular surface inammatory mediators.15 Rainbow glare as an optical side effect of light scatter from the posterior bed of the interface has recently been reported in 19% of the patients after IntraLASIK.16 The VOL. 147, NO. 2

visual impact was inconsequential in the vast majority of the patients and the incidence appeared to drop with the newer focusing optics of higher numeric aperture. The spectral pattern and visual angle of the subjective rainbow glare corresponded to a grating size that paralleled the raster spot separation of the IntraLase pulsing. Loss of vacuum in the suction ring during FS laser ap creation is usually not as serious a complication as with the mechanical microkeratome, and the suction ring may be reapplied and treatment resumed immediately in many cases. If the vacuum is lost during the side cut phase, a new side cut is made just inside the diameter of the interface cut. The curved applanating lens systems, on the other hand, are less adversely affected by premature vacuum loss. As the cornea is not forcibly attened, less suction is required and little or no corneal shape change occurs in the event of suction loss.

FEMTOSECOND LASERASSISTED LAMELLAR KERATOPLASTY


ANTERIOR LAMELLAR KERATOPLASTY: For ALKP, the laser is programmed to create anterior lamellar interface and peripheral trephination cuts of desired depths and diameters. The standard applanating lenses used to create LASIK aps are also used in laser-assisted ALKP. Laser treatment begins with formation of the lamellar cut at a depth determined by the corneal opacities to be removed. The trephination cut (6.0- to 9.0-mm diameter) is then performed by programming a circular pattern of contiguous laser spots to sequentially move in a posteroanterior direction, starting at the plane of the lamellar interface and ending slightly anterior to the corneal epithelium. The energy settings for the lamellar interface and the trephination cuts are similar to those used in LASIK. Trephination requires slightly higher energy levels than lamellar incisions since the cuts are across, rather than along, the stromal bers. For deeper ALKPs, the laser

FEMTOSECOND LASERS

193

FIGURE 5. Schematic diagram of posterior lamellar button creation for deep lamellar endothelial keratoplasty and donor cut in Descemet stripping with automated endothelial keratoplasty.

FIGURE 6. Some examples of shaped trephination congurations for femtosecond laserassisted penetrating keratoplasty.

energy levels are increased and the spot separation is set closer together in order to overcome laser scatter and attenuation caused by the additional thickness of stroma. The donor cornea (from either a whole globe or a corneoscleral button on an articial AC) is treated in a similar fashion. The anterior lamellar buttons are separated from the corneas in both the host and donor by sweeping open the lamellar interface with an instrument. The donor lamellar button is transferred into the host lamellar bed and sutured with either interrupted or running 10-0 nylon sutures.17 Early studies of FSassisted sutureless ALKP are showing promise.18
POSTERIOR LAMELLAR KERATOPLASTY (DEEP LAMELLAR ENDOTHELIAL KERATOPLASTY AND DESCEMET STRIPPING AUTOMATED ENDOTHELIAL KERATOPLASTY): FSassisted

posterior lamellar dissection techniques (Figure 5) have been studied in human eye bank eyes.19,20 and in rabbit.21 The laser treatment sequence for DLEK and DSAEK is the reverse of that of ALKP: the posterior trephination cut 194 AMERICAN JOURNAL
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precedes the more anterior lamellar interface cut. This prevents the intrastromal cavitation bubbles in the lamellar interface from blocking the subsequently arriving laser energy to the posterior trephination cut. A shorter applanating lens assembly is used instead of the standard applanating lens system designed to create LASIK aps and ALKP buttons. The shorter length allows the laser to be focused at deeper levels than in LASIK and ALKP. The posterior trephination (6.0- to 9.0-mm diameter) begins in the AC and progressively moves anteriorly through endothelium, Descemet membrane, and posterior stroma. To assure complete cuts deep inside edematous corneas, higher trephination energy levels than in LASIK or ALKP must be used. The lamellar plane is then cut at about 150 to 350 m anterior to the endothelial surface (Figure 5). The donor corneal button in both DLEK and DSAEK is cut from either a whole globe or a corneoscleral button mounted in an articial AC. The diameter of the lamellar dissection is intentionally made 1.0 to 2.0 mm wider than the trephination diameter (Figure 5), in order to ensure that these two cuts meet. This also allows the OPHTHALMOLOGY FEBRUARY 2009

cavitation bubbles to escape into the AC and the posterior disc to be completely separated from the trephination edges. In DLEK, the lamellar interface is entered from the anterior surface of either cornea or sclera via laser-cut tunnel incision. The host posterior corneal button is replaced with the donor posterior lamellar button. Light-microscopic histologic studies of the laser-cut posterior corneas showed smooth lamellar cuts with straight trephination edges. Scanning electron microscopic studies, however, showed an occasional mild stucco-like texture of the lamellar surface,20 possibly caused by laser scatter and attenuation in deep stroma. The FS laser is currently being investigated in cutting of the donor posterior corneal buttons by eye banks for use in DSAEK surgery.2224

The tunnel creation with the laser is not only easier and less awkward than with the traditional mechanical spreader method, but also is more precise, more predictable, and less likely to perforate cornea.29,30 In keratoconus patients, Rabinowitz and associates reported a trend toward better visual outcome with the FS laser over the mechanical spreader.30
FEMTOSECOND LASERASSISTED ASTIGMATIC KERATOTOMY AND ARCUATE WEDGE RESECTION: The FS

laser may be utilized in arcuate keratotomy and/or wedge resection for the correction of high astigmatism following PKP or cataract surgery. Laser-based corneal astigmatic surgery is easier, is more precise, and carries less risk of corneal perforation than the free-hand diamond blade method. Laser parameters, such as the width, arc length, and depth of the incisions, are set by the surgeon.31,32
OTHER USES OF THE FEMTOSECOND LASER UNDER LABORATORY INVESTIGATION: The FS laser may be

FEMTOSECOND LASERASSISTED PENETRATING KERATOPLASTY


THE FS LASER IS CAPABLE OF CREATING STRAIGHT TREPH-

ination cuts or complex-pattern trephination cuts for enhanced wound integrity of the graft-host junction. The latter includes the top-hat (with a larger diameter cut posteriorly), the mushroom (with a larger diameter cut anteriorly), the tongue-groove, the zig-zag, and the Christmas tree patterns (Figure 6). The choice of shapes and diameters in FS laser PKP or FS laserassisted keratoplasty (FLAK) or IntraLase-enabled keratoplasty (IEK) is dependent on individualized clinical requirements. The mushroom may be advantageous in keratoconus by providing a larger anterior refractive surface, while the top-hat may be advantageous in endothelial diseases by replacing more endothelial cells. The Femtec laser uses a decagonal trephination, which reduces rotational slippage of the graft. The patterned trephination is thought to not only increase the strength and structural integrity of the grafthost junction, but to also reduce the number of requisite sutures, lessen the amount of astigmatism, and possibly shorten the time of visual recovery.2528 As the procedure is still in its early investigative stages, the methodology is still undergoing evolution and the full extent of safety issues and complications are yet unknown.

used to cut a lenticule of central corneal stroma using intrastromal photodisruption with or without a ap (allFS laser treatment of myopia) or to cut a toroid of midperipheral stroma (allFS laser treatment of hyperopia).33 The Visumax system includes the FLEx (FS laser lenticular extraction) capability. The use of a FS laser microkeratome to aid in the creation of corneal pockets for the insertion of biopolymer keratoprostheses in human eye bank corneas has been studied.34 The FS laser can be used for obtaining diagnostic corneal biopsies (3-mm diameter and 120- to 200- m thickness) in suspected infectious keratitis.35 Ultra-short FS laser pulses have been focused in the subsurface of the relatively translucent perilimbal sclera for noninvasive glaucoma surgery (Liu HL, et al. IOVS 2004:45: ARVO E-Abstract 1002). Preliminary results of an experimental pilot study of FS laserassisted retinal imaging and photodisruption of retinal tissues using the same laser system was recently reported.36 The use of the FS laser in producing anterior lens capsulorrhexes in cataract surgery, corneoscleral, lens, and ciliary body modication for the treatment of presbyopia, and intracorneal pockets for riboavin instillation in keratoconus are also being investigated in the laboratory (Juhasz T, Ruiz L, Kanellopoulos J, Krueger R, personal communications, 2008).

OTHER USES OF FEMTOSECOND LASERS IN OPHTHALMOLOGY


INTRACORNEAL RING SEGMENTS:

FUTURE TRENDS
RAPID ADVANCES IN TECHNOLOGY CONTINUE TO IMPROVE

Intracorneal ring segments are arcuate, polymethylmethacrylate implants, for intrastromal insertion in the midperipheral cornea for correction of up to 3.50 diopters of myopia and for milder cases of keratoconus without central scarring. The FS laser may be programmed to create arcuate tunnels for implant placement at approximately 70% corneal depth.

the surgical safety, efciency, speed, and versatility of FS lasers in ophthalmology. Lower-energy nanojoule systems, combined with faster ring rates, may further reduce ancillary tissue damage over that of the current microjoule clinical lasers. Newer systems will also undoubtedly be smaller in size and weight, more portable, less susceptible to environmental factors, and less expensive. 195

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THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. BOTH AUTHORS WERE INVOLVED in the design and conduct of study; data collection; analysis, management, and interpretation of data; and review, approval, and preparation of the manuscript. The authors thank Drs Michael R. Banitt, University of Michigan, Ann Arbor, Michigan and Tibor Juhasz, University of California, Irvine, Irvine, California for their extensive critical review of the manuscript.

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17. Hoffart L, Proust H, Matonti F, et al. Femtosecond laserassisted anterior lamellar keratoplasty. J Fr Ophthalmol 2007;30:689 694. 18. Yoo S, Kymionis G, Koreishi A, et al. Femtosecond laserassisted sutureless anterior lamellar keratoplasty. Ophthalmology 2008;115:13031307. 19. Seitz B, Langenbucher A, Hofmann-Rummelt C, SchlotzerSchrehardt U, Naumann GO. Nonmechanical posterior lamellar keratoplasty using the femtosecond laser (femto-plak) for corneal endothelial decompensation. Am J Ophthalmol 2003; 136:769 772. 20. Soong HK, Mian S, Abbasi O, Juhasz T. Femtosecond laserassisted posterior lamellar keratoplasty: Initial studies of surgical technique in eye bank eyes. Ophthalmology 2005;112:4449. 21. Mian SI, Soong HK, Patel SV, Ignacio T, Juhasz T. In vivo femtosecond laser-assisted posterior lamellar keratoplasty in rabbits. Cornea 2006;25:12051209. 22. Cheng YY, Pels E, Nuijts RM. Femtosecond-laser-assisted Descemets stripping endothelial keratoplasty. J Cataract Refract Surg 2007;33:152155. 23. Jones YJ, Goins KM, Sutphin JE, et al. Comparison of the femtosecond laser (IntraLase) versus manual microkeratome (Moria ALTK) in dissection of the donor in endothelial keratoplasty: Initial study in eye bank eyes. Cornea 2008;27:8893. 24. Suwan-Apichon O, Reyes JM, Grifn NB, et al. Microkeratome versus femtosecond laser predissection of corneal grafts for anterior and posterior lamellar keratoplasty. Cornea 2006;25:966 968. 25. Farid M, Kim M, Steinert RF. Results of penetrating keratoplasty performed with a femtosecond laser zigzag incision: Initial report. Ophthalmology 2007;114:2208 2212. 26. Por YM, Cheng JY, Parthasarathy A, et al. Outcomes of femtosecond laser-assisted penetrating keratoplasty. Am J Ophthalmol 2008;145:772774. 27. Price FW Jr, Price MO. Femtosecond laser shaped penetrating keratoplasty: One-year results utilizing a top-hat conguration. Am J Ophthalmol 2008;145:210 214. 28. Steinert RF, Ignacio TS, Sarayba MA. Top-hat-shaped penetrating keratoplasty using the femtosecond laser. Am J Ophthalmol 2007;143:689 691. 29. Ertan A, Kamburoglu G, Bahadir M. Intacs insertion with the femtosecond laser for the management of keratoconus: Oneyear results. J Cataract Refract Surg 2006;32:2039 2042. 30. Rabinowitz YS, Li X, Ignacio TS, Maguen E. Intacs inserts using the femtosecond laser compared to the mechanical spreader in the treatment of keratoconus. J Refract Surg 2006;22:764 771. 31. Ghanem RC, Azar DT. Femtosecond-laser arcuate wedge-shaped resection to correct high residual astigmatism after penetrating keratoplasty. J Cataract Refract Surg 2006;32:14151419. 32. Harissi-Dagher M, Azar DT. Femtosecond laser astigmatic keratotomy for postkeratoplasty astigmatism. Can J Ophthalmol 2008;43:367369.
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33. Sletten KR, Yen KG, Sayegh S, et al. An in vivo model of femtosecond laser intrastromal refractive surgery. Ophthalmic Surg Lasers 1999;30:742749. 34. Sarayba MA, Kurtz RM, Nguyen TT, et al. Femtosecond laser-assisted intracorneal keratoprosthesis implantation: A laboratory model. Cornea 2005;24:1010 1014.

35. Kim JH, Yum JH, Lee D, Oh SH. Novel technique of corneal biopsy by using a femtosecond laser in infectious ulcers. Cornea 2008;27:363365. 36. Hild M, Krause M, Riemann I, et al. Femtosecond laserassisted retinal imaging and ablation: Experimental pilot study. Curr Eye Res 2008;33:351363.

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H. Kaz Soong, MD, received his undergraduate degree in electrical engineering from Massachusetts Institute of Technology in 1971 and graduate degree in bioengineering and neurophysiology from Cornell University in 1974. Dr Soong received his medical degree from Columbia University and completed his eye residency at Wilmer Ophthalmological Institute, Johns Hopkins Hospital. After a two-year cornea fellowship at Massachusetts Eye and Ear Inrmary, he joined the University of Michigan Department of Ophthalmology and Visual Sciences, where he is currently a Professor. Dr Soong is a member of the American Academy of Ophthalmology, Pan-American Association of Ophthalmology, and Ophthalmological Society of the West Indies. He is interested in international ophthalmology and is a recipient of the American Academy of Ophthalmology Honor Award. Dr Soongs research interests include femtosecond laser corneal surgery and ocular surface healing.

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Joo Baptista Nigro Santiago Malta, MD, received his medical degree from Catholic University of So Paulo, Brazil. He completed his residency in ophthalmology and clinical fellowship in cornea at Santa Casa Medical School, clinical fellowship in refractive surgery at the Federal University of So Paulo, and research fellowship in cornea, external disease, and refractive surgery at W. K. Kellogg Eye Center, University of Michigan. Currently, Dr Malta is an Assistant Professor of the Department of Ophthalmology, Division of Cornea and External Disease, Santa Casa de So Paulo, Brazil.

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