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OSN round table, part 2: How to become a better femtosecond laser cataract surgeon

Issue: January 2015

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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 second part of that wide-ranging discussion, moderated by William B. Trattler, MD, is featured in this issue of OSN.

Same surgeon for femto and phaco?

William B. Trattler, MD: The femtosecond laser portion of the cataract procedure is relatively fast. Most surgeons perform femtosecond laser on their own patients in a procedure room or in the operating theater. However, higher volume surgeons can consider working with another surgeon, where one surgeon performs the femto procedure and a second surgeon performs the intraocular portion of the procedure. Over the past few months, I have had the opportunity to work with my father, who is also an ophthalmologist. He performs the femto portion of the procedure in one room, and I am able to perform the intraocular portion of the procedure, flipping between two rooms. We work together as a team.

There is a learning curve when the surgeon does not perform the femtosecond laser portion of the procedure. For example, we treated a patient who had previously undergone laser thermal keratoplasty (LTK) for hyperopia, which left small round opacities in the cornea paracentrally. Following the femto portion of the procedure, I evaluated the eye under the microscope. I identified an area both within the nucleus as well as within the capsule that was untreated. It was directly underneath one of the LTK treatment opacities. It looked like Pac-Man took a bite out of the normal circle of the nuclear frag pattern and capsulotomy. Thankfully, I identified the situation before starting the intraocular portion of the case. I was able to use capsular dye to easily visualize the area of the capsulotomy that was incomplete. The point is that if you are not doing the actual laser surgery, you need to pay attention when starting your portion of the procedure to confirm that the laser procedure was completed as expected.

Pretreatment with nonsteroidals reduces the incidence of pupil restriction, according to H. Burkhard Dick, MD, PhD.

Image: Dick HB

Detlef Holland, MD: In our clinic, we have two different workflows. When I am doing the procedure, I do it all. I do the femto procedure and then also the surgery and everything in between.

I also do all of the femto procedures for another colleague, so I introduce myself to the patient and inform him that I will do the docking of the new machine. Afterward, he is moved to another room in our operating theater. We saw that the patient acceptance of this kind of workflow was high and that they were happy.

During the femto procedure, if I see something that is important, then I go to my colleague who is doing the phaco and explain what I saw so that he can be aware that there could be a possible risk. That is important.

Robert J. Weinstock, MD: There can also be issues for surgeons who are performing their own femto and doing phaco but also performing other standard phaco cases in the same rotation. The surgeon might do a femto case but then go do a standard cataract surgery, and maybe even another standard cataract surgery, before the femto case is moved into a room where the surgeon can do that case. Once in that rotation, the surgeon may forget what had happened on that femto case. There needs to be some type of protocol in place. When you do the femto, if there are any steps that are skipped or anything abnormal, you need to make a notation during the femto treatment, and that notation needs to follow the patient into the operating room. Then you would look at it as part of the time-out before you start the case to remind yourself what happened during the femtosecond treatment.

Bojan Pajic, MD, PhD, FEBO: In our cases in which one doctor performs the entire surgery, that is an advantage because you do not need to move the patient. You are under the microscope, and you do everything in the same place. After the femtosecond laser procedure, we see the results under the surgery microscope with high resolution, and then we go on immediately with the surgery. Thus, we are able to perform safely four cataract surgeries in an hour up to now.

Pavel Stodulka, MD, PhD: Since the early beginning, after the first few hundred eyes, the resident performs the laser and I perform the phaco at our clinic. We have trained three residents with a very short learning curve. This enables me to increase the efficacy of cataract surgery. We have done over 5,000 cases this way.

Time between femto and phaco

Holland: Another workflow issue is that there should not be too much time between femto and phaco. If one colleague does the femto procedure and the staff brings the patient to the other colleague who is doing the phaco, and perhaps he has an incidentally longer operation or another issue, then we should be aware that the femto case should not wait too long to avoid restricting of the pupil.

Trattler: That is an important pearl: The time delay between the femto and the phaco should be relatively short. In our center, the transition is relatively fast because we have our laser in our operating room. It is within 10 minutes, typically. How much time is it appropriate to wait?

Ronald Yeoh, MBBS, FAMS, FRCSE, FRCSG, FRCOphth, DO: I would say as soon as you can. It gives the eye less time to react. Sometimes my nurses ask me if I want to do my row of femtos first and then do the phacos. I say, “No, I’ll femto and I’ll phaco, I’ll femto and I’ll phaco.” That way, you are not going to have the problem of miosis.

Weinstock: As you introduce femto into your practice, when it is only maybe 10% or 20% use at first, there may be a little lag depending on how many operating rooms you are working in. Most surgeons operate in two operating rooms. Even if you do a femto case, I would advise maybe you do one standard cataract surgery in between while the patient is being moved into the room. So maybe it is good to alternate cases, but I definitely try to get the cataract out of the eye within 20 to 30 minutes of the laser treatment. The longer you wait, the higher the risk for miosis. There is no doubt that the laser treatment stimulates inflammation inside the eye, and inflammation causes miosis and could cause other issues, theoretically leading to more postoperative inflammation. It is important to have these patients treated under the femto and move quickly.

There are pros and cons to having the laser in the room where you move directly to the treatment. The big con in my practice is that I am trying to be highly efficient with the cataract surgery, so I do not want to have much downtime. If I do a femtosecond treatment, no matter how good we are, if it is in the same room, the best-case scenario is a 3- to 4-minute process before the patient is prepped, draped and ready for cataract surgery because right now we are not doing femtosecond laser treatments under sterile conditions. But if you do a sterile technique for the laser, you are immediately ready for cataract surgery.

Defeating miosis

H. Burkhard Dick, MD, PhD: If we talk about small pupils, the good thing is we know the reason why there is some pupil restriction. It is a prostaglandin release. So pretreatment with nonsteroidals is effective to reduce the incidence of pupil restriction.

I also think age is a factor. We published this in the Journal of Refractive Surgery. In another trial, we looked at what part of the lasering causes inflammation. Is it the corneal or lenticular component, the iris vessels or something like that? We did try looking at only corneal incisions on a prospective basis, only lenticular shots. That means only full fragmentation, the tightest grip you can use, the highest energy we can perform without capsulotomy. So the lens is then under pressure. This was done in 38 cases. Then we did the capsulotomy only. The main cause of miosis, by far, was the capsulotomy.

Interestingly, as a side effect, although we tremendously fired into the lens, there was no gas breakthrough, which you would fear. A breakthrough has not been reported by any Catalys (Abbott Medical Optics) users. It makes me confident to do a hydrodissection in every case to overcome the problem that has been associated and seen by many others in terms of cortex removal and stickiness.

Trattler: When you perform the laser capsulotomy, you are releasing lens particles into the anterior chamber. I do not think it is the laser energy that causes the pupillary miosis. Rather, it is (in my opinion) the lens particles released within the anterior chamber that appear to be the source of the inflammation causing the miosis. Do you agree with that?

Dick: We do not know. Now we are at the stage that we know it is inflammation. We need to address this medically. Omeros is looking at this in more detail now as to which specific drug we need to counteract and which regimen we have to follow.

We need to improve the capsulotomy and maybe the vertical spot spacing to increase the spot spacing. Maybe we can decrease the incision height. In another trial, we looked at temperature change. It is well described that a change of 0.1°C in a certain period of time may also induce miosis. It turned out that even with excessive lasering, only doing the capsulotomy, there was not that increase in any of the cases. It was not in vivo, but at least in these cases in which we only looked at temperature changes, you are firing a lot, depending maybe also on the platforms. This was about 4 mJ of energy; with higher energy, it may be different.

Weinstock: If new users see a patient who already has a small pupil to start with, say a 6-mm or 6.5-mm pupil, and let’s say they are doing a 5.5-mm diameter capsulotomy, the laser energy is close to the pupil margin already. So that case might be more predisposed to miosis than, say, a well-dilated pupil that is already pretty far away from the laser energy.

It also speaks to making sure you have a protocol after the laser to provide more mydriasis. If you anticipate that you are going to see some constriction of the pupil afterward, you may want to have some 10% phenylephrine to put in or maybe some more nonsteroidal. This is one of the areas of femtosecond laser surgery adoption in which you may have to make another possible change to your current technique. You have to have a plan for that, or you are going to be potentially surprised if you wind up with a small pupil by the time you get in the operating room.

Yeoh: What is your incidence of pupil constriction today? It is published at 20% to 25%.

Dick: It came down when we pretreated, so we are now at below 1%.

Holland: When we started doing femto cataract surgery, we had more patients with suction loss who we had to re-dock due to the old patient interface. We had much longer docking time than now, and we did not use Mydriasert (Thea Pharma), which we use now. In the first 3 months, we had between 10% and 20% of small pupils. Now it is around 1%, but not more. It is rare.

Yeoh: I use NSAIDs routinely as my dilation. I published a study I did on this in May 2014, and I had almost zero pupillary miosis. I do not think it is an issue.

Mark Cherny, MD: I agree. Almost insignificant, using nonsteroidals. I am interested to hear when people start the nonsteroidals and if they are also putting any nonsteroidal into the eye immediately after the treatment. I have started putting in an additional drop of Acular (ketorolac, Allergan) right after the laser so that it is in during the 20 minutes before they go to the operating room.

Dick: When do you start pretreatment?

Cherny: I start it 1 day before.

Holland: Pretreatment only some hours before the operation.

Yeoh: One day. I give it with the dilating drops an hour before surgery. I use two drops of nepafenac.

Trattler: Eric Donnenfeld performed a nice study 7 or 8 years ago in which he looked at four groups of patients undergoing cataract surgery with various regimens of preoperative topical NSAIDs. One group started topical ketorolac QID 3 days ahead of time, a second group started topical ketorolac 1 day ahead of time, the third group started ketorolac just an hour or 2 prior to surgery, and a final group underwent cataract surgery with no pretreatment. The study found a direct relationship between the amount of time topical ketorolac was started preoperatively and the maintenance of the pupil size during standard cataract surgery. Because of Dr. Donnenfeld’s study, I start topical NSAIDs 3 days prior to surgery. Since I started using the Lensar laser almost 2 years ago, I have not had an issue with pupillary miosis.

Yeoh: When we were all doing phaco, we kind of went away from the use of NSAIDs because phaco is quick. It takes us 5 or 10 minutes. You did not get the issue of pupillary constriction. So we all got a rude shock when we started doing femto-phaco because you saw this 20% of the time, and some of them came up to 2 mm.

Weinstock: By changing our protocol, we have almost completely eliminated miosis. We pretreated for the last 10 years with ketorolac, but now on every femto case immediately after the laser, we will give 10% phenylephrine automatically to everybody unless they have a significant heart condition or there is a health risk. I would say rarely, maybe 2% of the time, we would see miosis. It has all but eliminated miosis after femtosecond laser treatments.

Femto for complex cataract cases

Dick: When I started saying, “The complex cases are the indications for femto,” people would throw me out of the room. That was in 2010. In all of the lists and manuals, femto was contraindicated in all of the complex cases. But now we know the opposite, and we still are exploring techniques on how we handle, for example, intumescent white cataracts that are under pressure.

Weinstock: One of the biggest challenges that I find is that I will have some patients who are sent to me from assisted-living facilities or from the Veterans Administration. In these cases, we have very sick eyes with dense cataracts. But also, this is a demographic that cannot afford the surgery and has no resources to pay for it. I am looking at these eyes, saying, “These are the perfect eyes for this” — cases in which I truly feel the laser is going to benefit the patient and benefit me with less chance of having a complication. But they are some of the hardest patients to justify the financial cost and get under the laser.

Holland: We have the same impression. The difficult cases are absolutely the best cases. When we started and when I first saw the procedure on a video, I thought it would be something for refractive lens exchange only, but we soon realized, even when we regarded our phaco times, that especially for hard cataracts, the procedure is absolutely the best. But then we have an ethical problem. If you are convinced in these cases it is the better, safer procedure, then we have to discuss cost. In these cases, we cannot come to a point that we say, “He can’t afford it, so he’s not getting it.”

Stodulka: I think we are hitting on an important issue, which is the procedure fee. We should have never accepted that as an ophthalmic community. You pay for the laser, and then it is €10 per disposable pack, and that would solve the problem.

Trattler: Pavel, it is a challenging situation. Obviously, I prefer to avoid per-use fees for technologies. However, many companies have set up their business plans to offer a technology at a relatively low cost (low profit from the sale) and generate revenues with procedure fees. These companies use the revenues generated from the user fees to innovate and develop upgrades, which are often provided to their users at no additional cost. One challenge is that if we eliminate per-use fees, the companies would not have the money to invest in their infrastructure to develop upgrades to their technologies.

Stodulka: Let’s pay a little more for the laser. The per-procedure fee is killing the access to this state-of-the-art medical care in ophthalmology, especially in countries with lower purchasing power of their citizens. And in many countries it will not be possible to use this technology for difficult cases because of the high procedure fee.

Trattler: An initial cost for the laser that is double the price can still be a problem – don’t forget that there are fees to finance large capital acquisitions, plus interest fees when you borrow or lease the technologies. My recommendation is to just focus on keeping the per-procedure fees on the low side and also have the per-procedure fees reduce as usage increases. While per-use fees are not enjoyable, they do allow the laser companies to continue to innovate.

Weinstock: Both are great points. We want to support the continued development of the technology and the platform and the maturation of the technology, but at the same time, we would like to be able to offer this to all patients. Perhaps there is some kind of balance: If you had a sick eye with a dense cataract, what do you really need? You need the capsulotomy and fragmentation. Maybe we could find a balance in which the companies could provide us with different click fees based on what we are using, so if we are using it for, say, a refractive purpose and we are correcting astigmatism, that might be a different fee. If we truly need it for a patient who cannot afford it but we know that it is going to benefit that patient, it should be attainable. I myself will gladly pay the money and have it cost me extra to provide the service, and I will do it for free on some of these patients because I feel it is so beneficial. If we could have some help from industry to have a platform in which all patients can have access to it, it would be of great help.

Is femtosecond laser more efficiently used inside or outside the OR?

Practice size impacts workflow

Alice T. Epitropoulos

Implementing femtosecond-cataract procedures may require physical changes to a surgery center and will initially impact scheduling and workflow. The best ways to make the new structure work efficiently are still a matter of debate. At The Eye Center in Columbus, we have 75 surgeons, seven operating rooms and a designated laser room with our femtosecond and excimer lasers. Having a dedicated “laser” suite allows us to take advantage of the versatility of some platforms that have cataract and corneal (LASIK flap) procedure capabilities. The laser room is controlled for temperature and humidity, and has the same standards of sterility as the operating room. Patients undergo the femtosecond phase of the procedure, which takes about 5 minutes, and then are moved into the operating room, where they undergo cataract removal with IOL implantation.

Other centers prefer to perform the entire procedure in the operating room, minimizing the transition time between laser and phaco. If there is a problem with a patient at the laser or a laser issue that needs repair, the entire operating room goes down and nobody else can use it. With multiple surgeons in an ambulatory surgery center (ASC), it is not feasible to have the femtosecond laser in the operating room. The mobility and versatility of the “new kid on the block,” that is, Ziemer’s LDV, may change this mind set.

Regardless where the laser resides, appropriate scheduling is mandatory to prevent backlog of patients waiting for the laser procedure. The femtosecond procedure may initially be more time-consuming than traditional phaco, but it has the potential to improve patient outcomes and safety and become highly efficient and cost effective with one laser feeding several operating rooms in a high-volume ASC.

Alice T. Epitropoulos MD, FACS, is in practice at The Eye Center, Columbus, Ohio. Disclosure: Epitropoulos is a consultant for Bausch + Lomb.

Opt for efficiency

Mitchell A. Jackson

Every surgeon needs to decide on the proper operating room flow and efficiency when incorporating femtosecond laser technology. There is really no correct answer which setup (inside or outside the operating room) is best, but whatever brings the best efficiency is the correct answer. In an operating room setup with three or more rooms, having the femtosecond laser in its own clean room may be the best option to limit flow issues. In my setting, I have all the technology in one operating room, including intraoperative aberrometry with ORA (Wavetec) and the Lensar system (Lensar), which saves time and space by keeping the patient in the same bed under the laser or during phacoemulsification and IOL implantation. The minimal time added to perform femtosecond laser-assisted cataract surgery (2-3 minutes on average) saves time on the back-end phaco portion of the procedure, especially in difficult complex cataract cases involving pseudoexfoliation, intraoperative floppy iris syndrome risk, past trauma or extremely dense cataracts. I have a very high 80% conversion rate to femtosecond laser technology, so most of my cases require this all-in-one room setup to enhance efficiency anyway.

Another key advantage to having femtosecond laser in the operating room is the minimal effect of pupil size shrinkage because the transition to the phaco portion of the procedure is immediate. Pupil size tends to decrease after the femtosecond portion of the procedure because of the increase in prostaglandin levels delivered into the eye. In my hands, though, operating room efficiency and pupil size changes have essentially remained unchanged with in-the-OR femtosecond setup. Ultimately, having femtosecond laser technology in the operating room has improved the procedure’s efficacy and patients’ outcomes without disrupting flow and efficiency.

Mitchell A. Jackson, MD, is the founder and CEO of Jacksoneye, Lake Villa, Ill. Disclosure: Jackson is a consultant for Lensar.