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Femtosecond laser technology comes a long way over last decade
Practitioners have several laser choices for refractive cataract surgery, the next step with the technology.
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More than 3 million Americans undergo cataract surgery each year, with more than half of them older than age 65. Cataract surgery as we know it today is one of the safest and most commonly performed surgeries in the United States. The challenges faced by ophthalmologists are higher expectations from our patients because cataract surgery is now treated like refractive surgery and the financial pressures of obtaining LASIK-like outcomes to meet these expectations.
Femtosecond technology
Today’s refractive cataract patient is looking at cataract surgery as a chance to have a lifestyle change in his or her visual capability. From advancements in phacoemulsification technology to premium IOL options, intraoperative aberrometry capability, improved ocular surface therapies, better astigmatism algorithms, the newest guidance systems, better IOL calculation formulae and the latest in femtosecond laser technologies, the question remains: Have we finally arrived at the LASIK-like visual outcomes expected from our cataract patients?
It seems like yesterday when I did my first femtosecond laser first-generation LASIK flap with the IntraLase (Abbott Medical Optics) at a speed of 15 kHz and higher rates of interface keratitis, or what we now call diffuse lamellar keratitis. A decade later, diffuse lamellar keratitis is essentially gone, with 150 kHz speed with the iFS system and flap optimization in terms of sizing, shape, thickness and reduced energies applied. Oval flaps for astigmatism treatment, variable hinge positions and variable thickness for flaps as desired are a daily LASIK surgeon’s dream.
Other applications of femtosecond laser technology have expanded to surgical corneal applications such as creation of intrastromal channels for Intacs placements (Addition Technology), creation of corneal pockets for inlays and deep anterior lamellar keratoplasty procedures for anterior stromal corneal diseases. Not only have patient outcomes improved in these procedures, but safety has significantly improved with fewer adverse events and less liability for the premium surgeon.
The most exciting advance for me as a refractive cataract surgeon is the application of femtosecond laser technology to the cataract procedure. There are five systems cleared by the U.S. Food and Drug Administration for use of femtosecond laser technology as it relates to corneal and/or arcuate incisions in cataract surgery: Catalys (AMO), LenSx (Alcon), Lensar (Lensar), Victus (Bausch + Lomb Technolas) and Femto LDV Z6 (Ziemer). All but the Femto LDV Z6 have a capsulotomy clearance, and all but the Femto LDV Z6 and Victus have phacofragmentation clearance.
Choosing a system
The real conflict for the premium surgeon is how to choose among the various platforms. When I embarked upon this difficult decision process, it came down to cost, efficiency and capability. Our surgical center setup for cataract surgery requires an in-the-room femtosecond laser option, which left us with either the LenSx or Lensar, which do not have an attached bed, allowing for a patient to be kept on his or her usual cataract gurney for both the femtosecond laser and phacoemulsification portions of the procedure. This setup also allows the surgeon to do either consecutive or alternating femtosecond laser procedures without a disruption in flow or efficiency. By having the femtosecond laser in the OR, there is no lost time transferring patients from another room, further avoiding loss of pupillary dilation typically seen between the femto and phaco steps.
All platforms but the Lensar utilize optical coherence tomography for imaging, and I decided that the rotating cameras of the Augmented Reality Scheimpflug imaging with the Lensar system gives superior 3-D reconstruction of the eye compared with OCT to clearly see cataract density, with improved selection of fragmentation patterns, which results in reduction of ultrasonic energy and clearer corneas. The Lensar rotating camera system also rescans corneal incisions to improve depth accuracy of such incisions to prevent inadvertent perforations. Other systems require moving patients from the laser bed to the OR bed before the phacoemulsification procedure, which can slow the overall surgical efficiency process. Nevertheless, all of the FDA-cleared platforms are extremely advanced with their unique properties and advantages/disadvantages that work better or worse for the individual premium surgeon’s preferred OR setup.
In the end, I am excited to be starting femtosecond laser-assisted cataract refractive surgery at a level comparable to my most current generation femtosecond laser system for LASIK flaps, and with such technology combined with intraoperative aberrometry, I hope to achieve the same LASIK-like visual outcomes expected in today’s cataract population. The ultimate decision on femtosecond laser technology for the premium surgeon’s OR setting comes down to the business aspects, efficiency issues and clinical capability of each device desired. I hope a decade from now that current femtosecond laser platforms will be able to do corneal incisions, capsulotomy, phacofragmentation, phacoemulsification, cortical cleanup, intraoperative aberrometry and toric guidance all in one box.
Stay tuned for next month’s column — How important is the captain of the ship: Are premium surgeons still in charge?
Reference:
Donaldson KE, et al. J Cataract Refract Surg. 2013;doi:10.1016/j.jcrs.2013.09.002.For more information:
Mitchell A. Jackson, MD, can be reached at Jacksoneye, 300 N. Milwaukee Avenue, Suite L, Lake Villa, IL 60046; 847-356-0700; fax: 847-589-0609; email: mjlaserdoc@msn.com.Disclosure: Jackson is a consultant for Bausch + Lomb and on the speakers bureau of Abbott Medical Optics.