白内障新进展-飞秒激光辅助白内障手术 Advances in cataract surgery-femtosecond laser assisted surgery LIU XIAOYING RN , CHINA 12/1/2018

Learning Objectives 适应症To understand the uses of the femtosecond laser 仪器与设备的准备 To review the features of various systems and specifically the Alcon LenSx® Laser 飞秒激光的好处 To recognize the benefit of the femtosecond laser in cataract surgery 术前及术后的护理Pre- post patient care 激光安全防护简要Laser safety

飞秒激光简介What is a femtosecond laser? 飞秒（fs）是衡量时间长短的计量单位 1fs=10-15s -15 – to the minus 15

飞秒激光简介What is a femtosecond laser? 特点：脉冲形式 光爆破作用 靶向聚焦定位 没有热效应和冲击波 A laser that emits optical pulses with a duration in the range of femtoseconds (1 fs = 10-15 seconds ) Allows for precise cutting of tissue with minimal collateral damage( no indirect damage) Utilized since 2001 in ophthalmologic procedures such as LASIK, corneal transplants -15 – to the minus 15

晶状体摘除术发展史（白内障手术为例） 针拨 （B.C.600年，印度; B.C.200年，中国） 现代囊外（1949年，英国） 超声乳化（1967年，美国） 飞秒激光（2011年，美国）

超乳白内障手术的挑战性步骤 关键步骤 目前的手术 对屈光的影响 安全隐患 角膜切口 重视程度不够 散光 自闭性差 感染 中央连续环形撕囊(CCC) 大小不一 居中性差 有效晶体位置不一致 屈光结果难以预测 囊袋撕裂 悬韧带损伤 劈核 过多使用机械力及超声能量 视觉功能恢复延迟 内皮细胞丢失 角膜水肿 后囊破裂（PCR）

飞秒激光辅助的白内障手术 前囊膜截开 Anterior capsulotomy 晶状体碎核 Lens fragmentation 角膜切口制作 Corneal incision LRI切口制作 Limbal relaxing incision

Commercially Available Systems Alcon LenSx® (approved for all steps) LensAR® system (approved for all steps) OptiMedica Catalys® (approved for all steps) B+L Victus® (approved for corneal flaps, incisions and anterior capsulotomy) AMO Intralase® FS (used in LASIK flaps, approved for arcuate incisions only)

LenSx简介 高清OCT 参数控制面板 激光主机 眼球负压吸引环

高清OCT引导 360度实时扫描，扫描深度8mm 清晰分别角膜各层间，晶体前囊膜与后囊膜

飞秒激光白内障手术步骤 负压固定眼球 设置参数 发射激光

个体化设计的切口结构和位置

LenSx激光劈核 Chop模式 Cylinder模式 Since the femtosecond pulses are delivered optically through the cornea and anterior lens, the LenSx® Laser performs phacofragmentation without many of the mechanical effects and ultrasonic shockwaves/energy transmitted to the tissue by handheld phacofragmentation probes. The light pulses are focused to a small spot to achieve photodisruption of a tiny volume of tissue, a few microns in diameter, at the laser focus. A surgical effect is produced by scanning thousands of individual pulses in a specific pattern. There are two methods used for laser lens fragmentation – chop and cylinder. Each of these methods is customizable. For cataracts grade 0-2, the cylinder pattern is used enabling lens removal with only I/A and no phaco power. For higher grade cataracts, the chop pattern is preferred which greatly reduces manual manipulations as well as excessive phaco power and time Chop模式 Cylinder模式 13

手术刀 VS 飞秒 ——切口的密闭性

手术刀 VS 飞秒 ——撕囊的比较 前撕囊口全周需要覆盖IOL边缘0.5mm被认为是完美的撕囊

飞秒激光白内障手术的优势 前囊膜截开 晶状体碎核 角膜切口制作 多种切割方式 个体化程序化参数设计 静态碎核，提高手术效 率及安全 静态碎核，提高手术效 率及安全 对眼内组织损伤减少 精确的角膜切口 良好的眼球密闭 矫正散光作用 模式化撕囊： 量化中心定位 提高前囊膜截开的准确 性、可预测性及可重复性

适应症 禁忌症 飞秒激光白内障手术适应症 致密角膜白斑 常规年龄相关白内障 眼球震颤、术中不能固视合作 复杂白内障：晶体脱位、悬韧带 松驰、假性囊膜剥脱综合征、外 伤性白内障等独具优势 致密角膜白斑 眼球震颤、术中不能固视合作 瞳孔粘连，散瞳后直径小于7mm 结膜和其它眼组织粘连 致密硬核白内障 青光眼、视神经疾病为相对禁忌

手术录像 飞秒激光手术录像

Laser Safety

Light Amplification by Stimulated Emission of Radiation What is LASER? The word laser originates from the acronym for Light Amplification by Stimulated Emission of Radiation Definition: a source of high-intensity radiation produced as a result of stimulated emission.

Wave lengths of lasers

Characteristics of Laser light or Beam Monochromatic: composed of photons of the same wavelength or color. Collimated: waves that are parallel to each other Coherent: the waves are orderly and travel in the same direction 22

Potential hazards Electrical Fire and/or explosion Plume inhalation Laser Beam Laser beam: Laser energy absorbed by tissue has potential to cause damage. Degree of damage depends on thermal temperature and tissue sensitivity. Most commonly affected organs: Eye – cornea, sclera, lens and retina Skin 23

Laser injury to eye Laser wavelength is selectively absorbed by different ocular tissues associated with water, hemoglobin, melanin and protein Water inside corneal cells absorbs infrared CO² laser, and is vaporized Retinal hemoglobin absorbs visible Argon laser or Nd: YAG laser, and is coagulated

Laser Safety Management Structure Designate a Laser Safety Officer (LSO) LSO is in charge of laser safety and usage, as well as ongoing education of staff Implement policies and procedures for laser use Must include: Nature of hazards Safe keeping of laser key Staff training Safe operating methods Register of users Regular maintenance of equipment 25

Laser Safety Precautions Controlled access of treatment area Excellent communication General precautions Electrical precautions Fire and/or explosion Ocular precautions Patient safety precautions 26

Controlled Access of Treatment Area Post hazard signs on all doors Switch on laser caution lamps if available Cover all windows with appropriate black out covers Keep doors closed with protective goggles at entryway Essential personnel only in treatment area, reduce traffic 27

Laser warning sign and Barriers

Excellent Communication There should be direct communication between surgeon and the laser operator and all commands repeated The surgeon gives the laser commands and uses the foot pedal ( other foot pedals ) Observe any adverse condition, report and record 29

Authorized personnel ONLY to operate laser General Precautions Authorized personnel ONLY to operate laser NEVER operate laser without seeing aiming beam NEVER direct laser beam towards door DO NOT leave laser unattended while in use Place in stand by mode or switch off when not in use Avoid bumping laser machine Laser keys Nonreflective instruments 30

Electrical precautions Avoid incidents of electric shock Regular inspections and maintenance Maintain integrity of power cords, foot pedal, and circuit breakers Keep laser machine and foot pedal free from liquid spills or splatter 31

Fire and/or explosion precautions Emergency STOP as necessary Fire extinguisher available nearby Non-alcohol skin prep Non-flammable drapes, dressings and packs Anaesthetic agents should be noncombustible and when mixed with oxygen should be delivered in a closed system 32

Ocular precautions ALWAYS attach protective filter to microscope All laser eye wear should be inscribed with it’s Optical Density Provide safety goggles with sufficient Optical Density to all staff Ensure safety goggles have side shields Maintain correct care, use and storage of goggles Regularly inspect safety goggles for any damage Never use alcohol to clean laser goggles NEVER directly view laser beam 33

Ocular precautions Scrub nurse wearing protective goggles Microscope laser filter Laser treatment through indirect ophthalmoscope

Patient safety precautions Eye protection The eyelids can be taped shut on patients under GA Protective eye shields can be used on the eyes during ophthalmic procedures Corneal eye shields can be paced on anaesthetized eyes to protect the corneal tissue The prepping solution should be nonflammable and ensure no pooling of fluid around the skin Anaesthetic agents should be noncombustible and when mixed with oxygen should be delivered in a closed system Prevent inhalation of plume, by using a mask on the patient and staff. Smoke evacuation system should also be used. 35

Conclusion Lasers are distinguished from each other by the color of the wavelength and the laser medium. Laser systems create intense energy within very small areas giving rise to potential hazards, especially to eyes and skin Relevant understanding of lasers before therapeutic application is essential Recommended safety precautions must be followed in order to protect patients and staff from injury