This article is more than 5 years old. Information may no longer be current.
Indications for femtosecond lasers continue to expand
Click Here to Manage Email Alerts
The excimer lasers we use to reshape the cornea were initially developed in the 1980s and achieved U.S. Food and Drug Administration approval in the mid 1990s. While initially approved in the U.S. for surface ablation or PRK, almost from the day of FDA approval they were combined with a microkeratome in the procedure we call LASIK.
 Richard L. Lindstrom |
Femtosecond laser technology, originally targeted for intrastromal ablation to reshape the cornea, evolved under the visionary leadership of a small U.S. company, IntraLase, into a laser device to create flaps for LASIK surgery. The initial models were slow and difficult to use, had a set of complications of their own and delivered a flap that in many surgeons’ opinion was inferior to the then far-advanced mechanical microkeratomes. Fortunately, the company and a handful of innovative surgeon pioneers persisted, as the femtosecond laser has evolved to a position where it is seriously challenging the mechanical microkeratomes primacy as the instrument of choice for flap making.
Studies by many surgeons, including one by my associate Liz Davis and me, have demonstrated that even in the experienced microkeratome surgeon’s hands, rate of visual recovery, percent of patients who achieve 20/20 with one treatment, intraoperative complication rate and the number of patients eventually requiring an enhancement are usually improved when the femtosecond laser is adopted. I say usually because as I monitor large cohorts of outcomes, such as those generated at the TLC Vision Laser Centers, there clearly remain individual surgeons using a mechanical microkeratome whose outcomes rival the best of those obtained with the IntraLase laser used in other centers. Still, when the data of multiple surgeons using the alternative platforms is pooled, the femtosecond outcomes are superior, with better achieved visual acuities, a lower complication rate and a lower enhancement rate.
Considering that there are approximately 2,500 active corneal refractive surgeons in the United States, the increasing utilization of femtosecond lasers to create LASIK flaps should enhance overall outcomes and safety from a public health perspective.
Even more exciting is the probability that the femtosecond laser will find additional applications for the anterior segment surgeon. Early work suggests that a femtosecond laser can create a superior outcome when used in place of a trephine in keratoplasty. In addition, the femtosecond laser is being evaluated for the creation of intrastromal incisions that are capable of treating astigmatism, myopia, hyperopia and even presbyopia through the creation of a multifocal cornea. These femtosecond incisional corneal refractive procedures can generate the same patterns that we did freehand with diamond knives in the past, but with much greater accuracy, precision and reproducibility from one surgeon to another.
Finally, the femtosecond laser is also now entering the domain of the cataract surgeon. Early work suggests that a femtosecond laser can make exquisitely reproducible incisions for cataract surgery, create a perfect size and shape anterior capsulectomy, and even soften the nucleus.
It is easy to imagine the ophthalmic surgeon of the future sitting in the operating room at a surgical workstation that includes a femtosecond laser for all procedures. I see an exciting future for femtosecond lasers as their indications expand and they become available to an expanded number of surgeons worldwide.
- Dr. Lindstrom consults for or has a financial interest in Abbott Medical Optics, Alcon, Bausch & Lomb, LenSx and LenSar.