OSN round table: How to become a better femtosecond laser cataract surgeon

At the European Society of Cataract and Refractive Surgeons meeting, Ocular Surgery News gathered an international panel of experts to discuss their experiences with femtosecond laser-assisted cataract surgery, with the objective of improving the procedure. The first part of that wide-ranging discussion, moderated by William B. Trattler, MD, is featured in this issue of OSN.

William B. Trattler, MD: We are all experienced femtosecond-assisted cataract surgeons, and each of us has worked with one or more of the available femtosecond laser platforms. The first topic for discussion is educating patients on laser cataract surgery.

Mark Cherny, MD: A key part of my communication with my patients is to explain to them that we are privileged to have access in our center to this laser technology that I believe adds to the safety of the surgery and that I believe I should be doing this for all of my patients. We have been able to make it affordable. One hundred percent of my cataract patients are scheduled for laser.

Robert J. Weinstock, MD: What is it about the technology that makes you feel so strongly?

Cherny: No. 1, the more precise, controlled nuclear disassembly. No. 2, the consistency and safety of the capsulotomy. The reduced risk of the capsulotomy running out. No. 3, the architecture of the incisions I think adds to safety by giving a better closure of the wound. Although it is going to be hard to prove, I believe it is reducing the risk of endophthalmitis.

Trattler: Here at ESCRS in London, Harvey Uy, MD, presented data comparing the sealability of incisions created with the Lensar laser compared with a metal keratome. One of the unique attributes of laser-created incisions is that they can have a custom design to enhance their ability to seal. With this in mind, Dr. Uy reported that femtosecond laser wounds created using a custom design were less likely to require stromal hydration at the conclusion of the surgical procedure compared with wounds created with the keratome.

Weinstock: I think we are hearing more and more that fragmentation is rising in the ranks of value propositions for the laser. The majority and most devastating complications in standard cataract surgery are capsular tears. They happen most commonly during phacoemulsification and irrigation and aspiration. If the laser is going to reduce complications at those stages of the procedure by breaking up the nucleus and making it easier to get out of the eye, then we are looking at a significant advancement in the procedure.

Detlef Holland, MD: I would love if I could use femto on every patient. If I had the opportunity I would do it, but it is a problem of cost. We must actively educate patients. We need to advertise. We need to educate our referring colleagues on how important we think this new technology is because in Germany we have a lot of colleagues who are not doing surgery and they have a lot of arguments against femto cataract. We need to convince them that this is the future of better and safer technology. We recognize that the more the patients are informed, the more they ask on their own if we can do this new treatment. Interestingly, elderly people who are not interested in multifocals ask for the newer, safer technology.

Bojan Pajic, MD, PhD, FEBO: From what I have seen, femtosecond laser is safer forever for difficult cases. If there is a narrow pupil or a floppy iris, then you have an advantage. You cut. You make the fragmentation. Then you can perform surgery easily and much more safely than if you have mechanical forces on the lens during the capsulorrhexis, phacoemulsification and so on. We reduce the phaco energy significantly, so we lose fewer endothelial cells and have a better outcome in the first days.

Trattler: I agree. It has been my experience that the femtosecond laser makes cataract surgery safer overall for patients. and I share my positive experience with my patients. Besides having a centered, round capsulotomy in every case, I find that the lens fragmentation provides increased safety and repeatability of the procedure. The laser demarcates the lens, providing a clear sense of the depth of the phaco needle during sculpting. The nucleus, even in more dense cataracts, cracks easily. If there are any challenges during the procedure, such as the pupil reducing in diameter in eyes with intraoperative floppy iris syndrome, removal of the lens nucleus is still very simple because the lens nucleus has already been fragmented. Patients also experience faster visual recovery because less phaco energy is used during the procedure. This results in less corneal edema in the early postoperative period.

Ronald Yeoh, MBBS, FAMS, FRCSE, FRCSG, FRCOphth, DO: I use three platforms in Singapore: Victus (Bausch + Lomb), Catalys (Abbott Medical Optics) and LenSx (Alcon). I did not buy them, but the institutions I work in bought them. It is nice because I do not have a vested interest in saying that this machine is the best because I put a million dollars in it. I think it is an interesting journey in using the three different platforms.

My rate of usage is probably about 40% of my private patients. I could probably increase it quite easily, but cost always bears on my mind. I chat with the patients, and they often say to me, “Well, I’ll do whatever you say, doc.” But some cases that are easy or have soft cataracts, I think if a patient wants to save money, I will say, “Well, you’ll probably get just as good a result without femto.”

H. Burkhard Dick, MD, PhD: Even in a normal cataract, I would say femto is a benefit. Although I am experienced in cataract surgery, with femto you deliver consistency in terms of the capsulotomy.

Yeoh: Yes, I buy that. I have patients who are not wealthy, but if their son is going to pay for the surgery and they ask me, I will say, “If money is no object, let’s take the femto.”

Weinstock: I use the laser on 60% of my cataract patients. The deciding factor whether somebody ultimately chooses to get laser cataract surgery or not always comes down to cost. It is never a fear or concern about the technology. I tell my patients, “In my opinion, I feel that the laser is more precise than manual cataract surgery, and it allows me to do a safer surgery with a higher chance of reduced dependency on glasses after the procedure.” I also explain that traditional cataract surgery has an extremely high percentage of success and that we are talking about an incremental margin, so they are reassured they will do well even if they cannot afford refractive laser cataract surgery.

I prefer to use the laser if I have the opportunity. We now have created laser pricing to try to make it as affordable as possible to patients. We have a laser cataract package that is as low as US$750 per patient. We also have laser cataract surgery that includes a premium lens that is up to US$3,000 per patient. We are trying to give patients, even the ones who have limited income, the opportunity to get this technology. Much of the patient’s decision is based on how you communicate with them. If you are not confident in the technology, you are not going to speak the same way to the patient as someone who truly believes it is a benefit and feels the device helps drive better outcomes.

Dick: There is one thing I do differently. If it comes to the point that the patient asks, “Is it safer?” my team and I currently avoid making this assertion to patients. Whilst my personal assessment is that femto is adding to the safety of my surgery, our regulatory authorities may require a still stronger body of evidence before we can make such claims directly to patients in my country.

Weinstock: We are at a point in the evolution of femtosecond laser cataract surgery at which there is not enough of a pool of data or literature that we can say unequivocally that it is safer than conventional cataract surgery. But I personally do not think there is anything wrong with surgeons saying that they feel like they do safer and better surgery with the laser as long as they are being honest with themselves and their patients. The same thing happened with phacoemulsification. There was no point in time at which phacoemulsification became peer reviewed and all of a sudden it became the standard of care. It happened in a transition of time.

Cherny: I think that we have to be more prepared to tell our colleagues and our patients that we believe that this has made our surgery safer. When my nurse said to me, “Can you please organize an in-service training for vitrectomy because it’s been so long since we’ve done one that I don’t remember how to do it?” I knew this was making my surgery safer. I have not done an unplanned vitrectomy in more than 1,000 cases, and I could never have said that before. So I think we have to be prepared to tell our patients and our colleagues, “I believe this has made my surgery safer.” I have spoken to many experienced femto surgeons at this conference, and they all agree that it has made their surgery safer. I understand that there are issues about peer-reviewed literature and standards before we can make a broad statement, but if everyone around this table — an international group of extremely experienced femto surgeons — agrees that it made the surgery safer, I think it is legitimate to tell our patients, “We think this makes your surgery safer.”

Yeoh: It took a long time for phaco to prove superiority, but we did not wait for it. We all did phaco because we just knew it was better. I suspect that most of us in this room believe that femto is better or safer, or both.

Dick: If you ask me, it is not fair to compare the use of extracapsular vs. ultrasound and manual vs. femto. Femto is on a high level already with standard phacoemulsification, and if you look at the prospective, randomized, comparative trials with which you have sufficient power in terms of inclusion regarding the number of eyes, I would say the differences are small because we are already at a high level in terms of predictability and uncorrected visual outcomes.

Weinstock: I think a study needs to be done in which you take a subset of patients at high risk for complications, such as eyes with pseudoexfoliation, or eyes of patients who are on Flomax (tamsulosin HCl, Boehringer Ingelheim) or have had previous vitrectomies for other conditions or injections in their eyes — ones that we all would have trouble with. If you take that subset of challenging cataract patients and look at femto vs. non-femto, it would be an interesting case and probably easier to show the significant differences between complication rates in femto vs. non-femto.

Pajic: We are now at the beginning of the development of the femto-phaco situation. I am sure that all of the development in energy, spot scanning, frequency, imaging and other systems will be much better already in the near future. I think then the benefits of femto-phaco will be of a higher quality than we have it today.

Cherny: I often say that this is a disruptive technology, and one of the things that makes it so disruptive and challenging to surgeons is the fact that we are facing the law of diminishing returns. We are in a situation in which our previous technology and platform were relatively successful, and there is only a small step between where we were and perfection: Zero complications is what we are chasing. Unfortunately, in order to take that step from being very good to perfect, it is going to cost extra money. The challenging issue is how much extra benefit you get vs. how much it is going to cost.

Learning curve

Trattler: The other challenge for surgeons just starting out with femtosecond laser-assisted cataract surgery is that there is still a learning curve. While I feel I am experienced with laser cataract surgery, I recently made a change in my surgical technique that resulted in a few anterior capsular tears. Thankfully, all of the patients did extremely well. However, it demonstrated that surgeons need to be aware that there are some distinct differences in the surgical technique in eyes that have undergone femtosecond laser compared with eyes without laser.

Holland: We have to think about the learning curve. You have to change your technique, and I think when you start as a femto cataract surgeon, in the beginning of the learning curve, the corneas may look a little bit worse than before. When you are out of your learning curve, then you will see they are clearer. You do not need as much phaco time. You do not need to make so many movements in the anterior chamber because you can easily use the followability and holdability of the pieces after you break the fragmented nucleus because they just come straight to the tip. You only use vacuum or some short bursts of phaco.

Cherny: I think the learning curves are important, but for surgeons who are now embracing this technology, there are international, cross-platform and intraplatform learning curves, which we have traveled as a community. People who are starting with this technology are not going to have many of the little subtle issues that we may have had the last couple of years.

I think the time issue for experienced and high-volume surgeons is an important topic. Some high-volume surgeons say, “I’m now going to get a laser machine and start using it,” and they think that they are still going to be able to do 20 or 30 cases in a day. They are pushing the limits of their capacity, or even safety, by trying to maintain their high volumes while they are learning and embracing this into their practice. Some surgeons may have to reduce the number of patients on a list to achieve maximal safety with this technology.

Integrating into practice

Weinstock: There are critical components to success with the laser, and one is from a patient education standpoint: the process of your staff and technicians understanding the advantages of laser.

There are also issues for the surgeon in terms of the physical learning curve and changing their technique.

Then there are learning curve issues related to flow in the operating room, bringing in a laser and still maintaining volume, and adjusting your schedule. Those are three components surgeons need to address in their practice to have a higher likelihood of success integrating femtosecond laser cataract surgery.

Cherny: As far as maximizing success and safety with this technology, one of the issues that may be relevant is how often one actually uses it and what proportion of your surgery you are doing with it. I do not think that I would be as good and as safe with this femto technology if I were doing it in only 5% of cases. The proficiency and safety that I am delivering to my patients is partially based on my frequent use of the technology.

Weinstock: It makes sense to have it be part of routine cataract surgery. It would not surprise me if at some point in the future it was considered standard of care in developed countries as the technology improves.

Holland: I think it is not a question of percentages; I think it is a question of daily routine. At the moment, I use it daily, 5 days a week.

Cherny: If you are doing it daily, I think that you would be well experienced with it. But there are many surgeons in communities who may be doing only 200 cataract cases a year, and they may do a femto case only once a month or every 2 months. I think that situation is not going to give you the best laser cataract surgery results.

Holland: We have data about our learning curve regarding phaco time and the time of the procedure. We can see, over 2 years, the time that I am using is still decreasing. Phaco time also still is decreasing because I changed some of the parameters of the phaco machine, and I am getting more used to it, so the speed is increasing.

Pajic: All parameters are important. The workflow and the patient flow have a high impact because it is our daily business to make the whole procedure as fast as possible with the highest possible quality. It also makes it less expensive if there is a good workflow and if we do not have more nurses or technicians than needed. We saw in the first 5 surgery days a significantly decrease of the overall surgery time. I asked the question of how many procedures per hour we should do without incurring supplemental costs. We calculated that we should perform three cases per hour. Now we are at four cases per hour with femto. With phaco alone, we are able to perform up to eight. Now we are being cautious with our number of cases.

Read part 2 of this round table in the Dec. 25 issue of Ocular Surgery News.

• Mark Cherny, MD, can be reached at Cataract Clinic of Victoria, 961 Glenhuntly Road, Caulfield South, 3162, Australia; 61-411-011966; email: markcherny@cataract.com.au.
• H. Burkhard Dick, MD, PhD, can be reached at University Eye Clinic, University of Bochum, In der Schornau 23-25, 44892 Bochum, Germany; 49-234-299-3100; email: burkhard.dick@kk-bochum.de.
• Detlef Holland, MD, can be reached at Augenklinik Bellevue, Lindenallee 21-23, 24105 Kiel, Germany; 49-431-30-10-8-0; email: d.holland@augenklinik-bellevue.de.
• Bojan Pajic, MD, PhD, FEBO, can be reached at ORASIS Eye Clinic, Swiss Eye Research Foundation, Titlisstrasse 44, 5734 Reinach AG, Switzerland; 41-62-765-60-80; email: bpajic@datacomm.ch.
• William B. Trattler, MD, can be reached at 8940 N. Kendall Drive, #400, Miami, FL 33176; 305-598-2020; email: wtrattler@gmail.com.
• Robert J. Weinstock, MD, can be reached at the Eye Institute of West Florida, 148 13th St. SW, Largo, FL 33770; 727-585-6644; email: rjweinstock@yahoo.com.
• Ronald Yeoh, MBBS, FAMS, FRCSE, FRCSG, FRCOphth, DO, can be reached at #13-03 Camden Medical Centre, 1 Orchard Blvd., Singapore 248649; 65-6738-2000; email: ronald_yeoh@snec.com.sg.
• Disclosures: Cherny is the owner of a Catalys system and day surgery center. Dick is a consultant to AMO, Bausch + Lomb and Zeiss. Holland is a consultant for Lensar. Pajic has no relevant financial disclosures. Trattler is a consultant to Lensar, AMO, Alcon and Bausch + Lomb. Weinstock is a consultant for Alcon, Bausch + Lomb and Lensar. Yeoh is on speaker panels for Alcon and AMO

What are the advantages/disadvantages of having the same surgeon perform both the femto and phaco portions of cataract surgery?

Account for patient’s perspective

Patients are usually most aware of who is doing the laser portion of the cataract procedure because he or she is less sedated and wears no drape to cover the other eye. It is the more frightening part of the procedure. Having a single surgeon perform all aspects of the procedure is the cleanest way to proceed because the patient has a bond with one surgeon and has little question as to who actually did the surgery. From a patient’s perspective, it is all a part of the same procedure. Patients are not concerned with understanding how dividing the procedure among two separate operating surgeons is of logistical benefit to the practice, the surgery center or the surgeon.

For most of us, our biggest source of referrals is from past patients with whom we have a bond. We do something to disrupt those bonds when we introduce another surgeon to do a portion of their procedure. We commoditize our work, and we lessen the importance of the relationship between doctor and patient.

Besides that, there are usually ways to work out the logistics so that there is no significant loss of time for a single operating surgeon to do all aspects of the procedure, even in high-volume practices, where some surgeons prefer an assembly line type of workflow. You do not need to disrupt the efficiency of that workflow.

John A. Hovanesian, MD, FACS, is OSN Cataract Surgery Section Editor. Disclosure: Hovanesian consults with a number of health care companies.

One surgeon, two technologies adds time

The major disadvantage of having the same surgeon perform both the femto and the phaco portion of the cataract surgery is the additional time required to have the surgeon alternate between the two technologies, especially if the femtosecond laser is not immediately adjacent to the operating room. By using a separate surgeon for each portion of the cataract surgery, time can be maximized and expertise can be developed by both surgeons in their respective aspect of the cataract surgery.

The advantage of femtosecond cataract surgery is that it is a digital procedure in which there is little or no variation in surgical effect based on the surgeon. A second surgeon performing the femtosecond laser can develop extensive expertise by dedicating his time and effort to this portion of the procedure.

My prediction is that eventually, surgical centers will have dedicated femtosecond laser surgeons who will be performing this procedure for all of the phaco surgeons. By doing this, the time spent in the OR can be dramatically reduced, efficiency can be increased, and results should improve as the dedicated femtosecond laser surgeon gains more expertise with the procedure.

Eric D. Donnenfeld, MD, is an OSN Cornea/External Disease Board Member. Disclosure: Donnenfeld is a consultant for Alcon, Abbott and Bausch + Lomb.