Refractive surgery in France changing

SFO president discusses hot topics, including PRK over LASIK and angle-supported phakic IOLs.

PARIS – Refractive surgery in France will be concentrated in a few centers that are able to provide updated equipment, high-quality customer service and top standards of care.

Béatrice Cochener

“Small practices, where the standards of care, the volume of surgery, and the quantity and quality of equipment are variable and difficult to assess, are going to gradually disappear,” According to Béatrice Cochener, MD, president of the French Society of Ophthalmology.

The large centers will be private but accredited by national health authorities, attract the best specialists, undergo strict quality control and be able to afford the most innovative technologies.

She believes LASIK complications can be minimized if preop assessment, patient selection and the procedure are performed competently by experienced specialists using specialized technology.

“We now use the Ocular Response Analyzer (Reichert). ... They are precious instruments that in expert hands can detect risk factors for ectasia in patients that only a few years ago would have been judged as eligible,” she said. “We are opening an umbrella over LASIK, made of a series of parameters that delimitate the area of safe surgery.”

Making refractive surgery safer

Ectasia after LASIK, was never a big issue in France because LASIK never had a prominent position here.

“I would estimate that no less than half to two-thirds of our corneal photoablation procedures were PRK,” she said. “After the problems with ectasia were raised, even the best advocates of LASIK, such as myself, have dramatically changed the proportion of their choices in favor of surface ablation.”

But with an accurate patient selection, LASIK can be safer. PRK, with new ablation profiles, customization and delivery systems, is also safer, better.

Corticosteroids are still the first choice treatment for regression or early haze.

“We should consider more the secondary effects they have on intraocular pressure and abandon their routine use,” she said.

Some controversy has been raised by cases of corneal ulcers produced by the prolonged use of NSAIDs. Used for 4 days or more, they have been proven to delay the wound healing process, Prof. Cochener said, adding that mitomycin C is not used routinely by most French surgeons, but only in selected cases.

Limited femtosecond laser use

Femtosecond laser as an alternative method to cut the LASIK flap is still not the standard in France.

According to Prof. Cochener, transepithelial LASIK may be a good option with femtosecond laser, but there are still problems with controlling tissue vacualization and refraction predictability.

After the creation of a flap, the second-most common application of the femtosecond lasers held by French centers is penetrating keratoplasty.

“Lamellar grafts is what most of us would like to do, and there is research going on in that direction. However, the femtosecond lasers that are sold on the market don’t all have these capabilities,” Prof. Cochener said.

Full-thickness cuts have shown good outcomes, but they do not produce watertight, sutureless grafts.

Presbyopia: a cautious attitude

Presbyopia correction is an expanding business, with a variety of options.

“Multifocal lenses are currently in the first position,” Prof. Cochener said.

She said the concept of restoring accommodation is not popular.

“Results with the various currently available accommodative IOLs were, frankly, poor, and scleral techniques seem to us too invasive to justify the little effect,” she said.

Lens-based presbyopia correction, however, is not an easy choice.

“Clear lens exchange is not so popular in France, particularly after the publication — by Joseph Colin a few years ago — of the alarming data on retinal detachment. We do believe that multifocal lenses are a valuable option. But never perform lens surgery under the age of 55 and always in presence of some posterior vitreous detachment and loss of crystalline lens transparency,” she said.

For patients younger than 55 years who are asking for presbyopia correction, she offers presby-LASIK, although this is controversial.

“We are still using presby-LASIK only in young presbyopic hyperopes and not in emmetropic or myopic patients,” Prof. Cochener said.

Angle-supported phakic IOLs

Phakic IOLs are the only option for high ametropia in a young patient with a clear natural lens, Prof. Cochener said.

Despite France’s history with angle-supported IOLs, she believes in a future for angle-supported phakic IOLs.

“New systems of visualizing the anterior chamber, like the Artemis (ArcScan) and the Visante OCT (Carl Zeiss Meditec), offer a more solid, scientific basis for IOL selection,” she said.

The angle-supported Alcon AcrySof has reached almost 7 years of follow-up under, and it received the CE mark in July.

“The great advantage of this lens is the high adaptability,” Prof. Cochener said.

In France and other European countries, ophthalmologists start earlier than in the United States with new techniques and technologies.

“If used ethically and professionally as we do, it’s a wonderful opportunity, and I am sure that our American colleagues think we are lucky,” she said.

For more information:

• Béatrice Cochener, MD, can be reached at the Department of Ophthalmology – University of Brest - CHU Morvan - 5, Av. Foch, 29609 Brest CEDEX, France; e-mail: beatrice.cochener-lamard@chu-brest.fr. Prof. Cochener has no direct financial interest in the products discussed in this article. She was a clinical investigator for Alcon.

• Michela Cimberle is an OSN Correspondent based in Treviso, Italy, who covers all aspects of ophthalmology. She focuses geographically on Europe.