**4. Description of the intervention**

#### **4.1 Capsulotomy**

The capsulotomy cut opens the lens's anterior capsule in a continuous, curvilinear, and circular fashion with high precision to improve safety during intraocular maneuvers. We advise to choose a 5.2 mm diameter capsulotomy, with a delta up at

**27**

*Femto Laser-Assisted Cataract Surgery*

*DOI: http://dx.doi.org/10.5772/intechopen.88821*

with highly predictable sizes [20–22].

*4.1.1 Lens fragmentation*

*4.1.2 Limbal relaxing incisions*

**4.2 After the laser procedure**

full of balanced salt solution.

*4.3.2 Pupillary constriction*

**4.3 Complications**

*4.3.1 Suction break*

*4.1.3 Corneal incision*

400 μm and a delta down of 350 μm. The energy recommended is 15 μJ, with a 4 μm spot separation and a 3 μm layer separation. Laser capsulotomies have been shown to be better centered than manual continuous curvilinear capsulorhexis (CCC),

The surgeon defines the pattern, the length, and the number of cuts. The energy level, the anterior and posterior lens capsule parameters, pattern separation and the primary incision angle have to be specified. Then, the nucleus can be easily split.

It is possible to correct a small amount of astigmatism (<1.5 D) with arcuate incisions (AI) [23]. Nomograms can facilitate surgical planning by determining the proper treatment for an intended correction [24]. Arcuate incisions can be left unopened until

All corneal incisions are placed just inside the limbus. The real-time anterior segment imaging provides the peripheral corneal thickness at the location of the incision during the procedure. We recommend a 2.2 mm three planes (90°/11°/90°) main incision at 135° and a one plane 1.2 mm incision at 5° for the side-port incision.

After removing the docking system, next steps are similar to manual phacoemulsification. The cortex aspiration can be tricky because the femtosecond laser cut it just below the capsulotomy. If the irrigation/aspiration probe is not sufficient, a Simcoe cannula can be used. To help, the cortex may be washed with a 25G syringe

Sudden suction break can occur in less than 2% of cases, but did not lead to further complications as laser treatment can be started over (**Table 4**) [19]. Most important factors to prevent it are precise patient interface placement and good preoperative anesthesia. Hard headrest avoids the head from being pushed down during insertion of the patient interface and reduces the risk for suction loss.

The incidence of pupillary constriction is 19% and arises during the first steps of the femtolaser procedure [19]. The laser application itself can cause pupillary miosis. Bubble formation in the anterior chamber releases small amounts of free radicals and prostaglandins that can trigger pupillary constriction. Highly myopic eyes and eyes with pseudoexfoliation syndrome are prone to a miotic reaction after femtosecond laser treatment. Intracameral epinephrine before lens removal can help enlarge the pupil and facilitate the surgery [26]. Iris hooks, retractors or a

the postoperative period depending on the postoperative refractive error [25].

The spot the layer separation should be 4 μm with an energy level of 5.5 μJ.

#### *Femto Laser-Assisted Cataract Surgery DOI: http://dx.doi.org/10.5772/intechopen.88821*

400 μm and a delta down of 350 μm. The energy recommended is 15 μJ, with a 4 μm spot separation and a 3 μm layer separation. Laser capsulotomies have been shown to be better centered than manual continuous curvilinear capsulorhexis (CCC), with highly predictable sizes [20–22].
