This article is more than 5 years old. Information may no longer be current.
Is the age of microkeratomes coming to an end?
Click Here to Manage Email Alerts
Femtosecond lasers are the future
 Bojan Pajic |
Whenever I am asked the crucial question “will microkeratomes survive in the age of femtosecond lasers,” I answer that we should consider this matter from two different viewpoints. The first is the medical science view. The second is the money issue.
Clinically, the main argument against femtosecond lasers used to be the much lower cutting speed compared with microkeratomes. The longer suction time of the eye was a concern, although the suction pressure was lower than with a microkeratome. A further argument against the first-generation low-frequency femtosecond lasers was a rough cutting surface. With the development of a new generation of femtosecond lasers, these disadvantages have been largely overcome.
Personally, I now perform 90% of my LASIK procedures with a femtosecond laser. I use the IntraLase, but more often the Ziemer LDV.
I have performed thousands of procedures and would not hesitate to say that flap quality, smoothness of the bed and safety are now much higher than with even the best microkeratomes available. In addition, if a cut failure occurs, you can immediately reattempt the cut with femtosecond lasers, without the prolonged waiting times for reoperation required by mechanical keratomes.
Recently, we have compared in a prospective study the results of LASIK in 938 patients overall. In one study, the LDV laser was used in one eye and the Amadeus SIS microkeratome in the other eye to create the flap. The precision of the femtosecond laser regarding flap thickness was highly significant compared with the microkeratome. Surprisingly, a significant visual acuity increase was found in the femtosecond group, whereas the visual acuity in the microkeratome group remained stable.
The technical advantages of the LDV femtosecond laser compared with other systems are that you don’t have to move the patient during the whole LASIK procedure and that the laser is stable; it is said that you can use it in different rooms and hospitals within 1 hour.
The other aspect to be considered is cost. Microkeratomes are much cheaper, and for many of my colleagues, this is still an important argument. However, patients are generally ready to pay a higher price for increased quality and safety and to have laser rather than blade surgery. Cost is always an issue, but an issue that has never stopped scientific progress.
In conclusion, I’m sure that femtosecond lasers will replace microkeratomes. The future of the femtosecond laser leads to faster technical systems with a further decrease of energy and spot diameter. Clinically, the surgery indication range will increase to include not only refractive and corneal surgery, but also cataract and glaucoma surgery. Looking at the big picture, the volume of surgery will indeed financially justify the initial investment.
Bojan Pajic, MD, is Chairman and Medical Director, AugenZentrum Pajic and Research Institute, Reinach, Switzerland.
Microkeratomes are here to stay
 James S. Lewis |
My ideal femtosecond laser would be small enough to fit under my excimer platform and eliminate the need to move patients from one device to another; rarely need service and when necessary the manufacturer could ship me a loaner unit overnight; not leave tissue bridges and therefore allow me to lift all flaps atraumatically; not leave air bubbles in the stroma or anterior chamber and would never produce a surgical delay or prevent iris registration; produce almost no inflammation and would not require intensive topical steroids; consistently create perfect flaps between 95 µm and 105 µm with a 3.5-mm hinge and 8.5-mm diameter; be almost devoid of diffuse lamellar keratitis; be disposable and portable; and not have a click fee. Last but not least, it would cost under $40,000, have an annual maintenance contract less than $4,000, and cost less than $100 to operate per case.
When they make my ideal femtosecond laser, I will consider giving up my Moria One Use-Plus SBK mechanical microkeratome.
However, I am not sure this will ever happen. What I can see now is that, during surgery, the flaps created by the SBK are thin, dry, resilient and natural. The femtosecond flaps look edematous, white, rubbery and unnatural. I believe the flaps created by finely honed steel are more physiologic than those generated from a series of tiny plasma explosions. I admit, we haven’t yet found any clinical correlation to these findings, but the track record for steel is well-established, while there are many unknowns in the long-term effects of femtosecond laser energy delivered to the cornea.
I also doubt we will ever be free from a click fee. Years ago, the Harvard Business Review suggested that industry “share in the surgeon’s success” with laser vision correction. Most excimer laser companies and all femtosecond companies have strictly adhered to that recommendation.
I am loyal to my Moria, unmoved by marketing pressures, immune to industry propaganda and ignoring the well-paid pundits. I am confident I am providing the best care, making the best flaps, and respecting the integrity and physiology of corneal tissue. I am working cost-effectively without being victimized by yet another predatory click fee.
Those surgeons confident in their clinical skills, respectful of corneal tissue and interested in controlling costs will stand firmly with Moria’s One Use-Plus SBK. Mechanical microkeratomes are here to stay. I look forward to the next generation of Moria mechanical microkeratomes, perhaps with a choice of hinge positions.
James S. Lewis, MD, practices in Elkins Park, Pa., U.S.A. He is Director of LASIK and Corneal Surgery at the Pennsylvania College of Optometry and an active member of the Wills Eye Surgical Network.