Comment on: Outcomes of femtosecond laser–assisted cataract and refractive lens surgery in patients with prior radial keratotomy

We would like to congratulate Trinh et al. for their excellent publication, which deals with individuals who in their younger days underwent radial keratotomy (RK) and who now had femtosecond laser–assisted cataract surgery (FLACS).1,2 We have performed FLACS ever since we reported on our first 6 eyes a couple of years ago.3 Our experience, however, differs from the one described in the recent paper. Most crucially, we definitely do not concur with the authors' recommendation to avoid using FLACS in this group of patients. We are dealing with individuals who value the independence from spectacles that RK seemed to promise them back in the day. Some intraocular lenses (IOLs) are more beneficial for these patients than others; in our experience, they often prefer a monofocal plus IOL, a light-adjustable IOL, or the IC-8 (Acufocus, Inc.). When implanting these IOL designs, the surgeon would certainly want to have the best possible capsulotomy because these eyes have an increased risk for intraoperative complications. In case of a posterior capsule rupture, a perfect capsulotomy gives the surgeon the option to solve the situation by performing optic capture.4 Those patients tend, in general, to come at an earlier age and an earlier stage of cataract formation to the clinic, which means applying the laser for fragmentation is in most cases not necessary but renders visibility of the capsulotomy more difficult. We have adapted the laser settings for these eyes and are happy to share them: for vertical spot spacing, we increased from 10 to 15 μm.5 In addition, we have changed the energy level and increased it from standard settings to 8 up to 10 μJ on the Catalys Precision Laser System (Johnson & Johnson Vision). Our colleagues from Toronto were not using these important adaptations. Unfortunately, based on our ongoing experience with other femtosecond laser platforms, these setting adaptations are not transferable. As Trinh et al. describe it in their discussion, “capsulotomy parameters were not modified from our usual practice.” We believe that special settings and care are a “must” in these eyes. Equally important is a thorough preoperative evaluation: some of these old corneal incisions have turned into relatively dense scars. These areas can be marked before treatment with a chalky marqueur; the capsulotomy size will be adapted appropriately within a range from 4.5 to 5.1 mm. We also recommend to always apply VisionBlue and perform the adapted Dimple-down maneuver—in very rare cases with the help of an endgrasping 23G capsulorhexis microforceps instead of an Utrata forceps, which may lead to a shallowing of the anterior chamber. In our experience with currently 15 patients more than reported in 2016, we have not seen a single capsule rupture or any other noteworthy complication. It will not be possible, however, to completely avoid complications because we are dealing with a very special group of eyes. Therefore, sharing one's experience, as Trinh et al. have done, is valuable for the entire refractive and cataract surgery community.

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