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Does use of femtosecond laser represent another crossroad in cataract surgery?
When any new technology is introduced into surgery, there is a period of time in which the merits of its use will be debated. The use of the femtosecond laser in cataract surgery is no exception.
In this issue of Ocular Surgery News Europe Edition, a round table discussion among femtosecond laser users is published. The title is “How to become a better femtosecond laser cataract surgeon.” It is certainly filled with useful information for those about to start introducing the laser into their practice. One of the interesting points to come out of the discussion was whether it was reasonable to say to patients that femtosecond laser was safer and would give better outcomes.
Burkhard Dick, MD, PhD, was very clear that in Germany this would be frowned upon because the data so far do not indicate any improvement in safety or visual outcome. Others on the round table said they felt that because the procedure was more precise and consistent, it felt safer in their hands. Although there have been marginal improvements in spherical equivalent in all the studies that have reported this, they are not visually significant.
In an article by Mastropasqua and colleagues in the December 2014 issue of the Journal of Cataract and Refractive Surgery, this is reported as a spherical equivalent variation for two laser platforms as 0.21 ± 0.40 D and 0.20 ± 0.72 D and for manual capsulotomy as 0.28 ± 0.28 D. Most patients cannot differentiate 0.07 D differences.
The largest comparative study of safety between laser and manual-assisted cataract surgery is from Abell and colleagues in the January issue of Journal of Cataract and Refractive Surgery. They compared 1,852 laser eyes with 2,228 manual eyes and found few differences. The incidence of anterior capsule tears was higher in the laser group at 1.84% compared with 0.22% for manual capsulotomies. There was also a higher incidence of corneal haze and miosis in the laser group, albeit a small but statistically significant percentage.
The French authorities have initiated a study of 2,000 eyes comparing laser and manual surgery, as has the Veterans Administration (VA) in the U.S. This latter group has undertaken a meta review to assess the effectiveness, safety, adverse consequences and cost-effectiveness of femtosecond laser use in cataract surgery. This review was further reviewed by Wu and colleagues in the January issue of Journal of Cataract and Refractive Surgery.
Although the results analyzing the VA’s review look good, in order for the VA to recommend the use of femtosecond lasers in their facilities, largely used for surgical training, further studies — not just of efficacy, safety and cost-effectiveness — will be needed. These studies will then need to be subjected to systematic review to assess their value.
Despite the fact that there does not seem to be any real difference in outcomes between current manual techniques using phacoemulsification and laser-assisted surgery, the mood of the round table participants was very certain. They all felt, as regular users of laser technology in their cataract surgery, that this would become the standard of care in the not-too-distant future. The main factor holding back further take-up of this technology for most surgeons was said to be cost. Although the surgeons in the round table are happy to tell their patients that the procedure is more precise, and this is not in dispute, and further that they feel comfortable with the laser in their practices — is greater precision and consistency alone sufficient to justify the extra cost? This is particularly true for state-funded health care systems.
However, for surgeons wishing to start using femtosecond lasers in their cataract surgery, this round table discussion has some useful pointers. They highlight integrating this technology into their practice, structure workflow, understanding the learning curve, use in more complex cases and persuading patients the extra cost is worthwhile. It remains to be seen whether this particular crossroad in cataract surgery will lead to two different approaches: the use of femtosecond laser in large essentially refractive practices and smaller largely cataract-based practices and surgery carried out in state-funded facilities, where traditional manual phacoemulsification will continue for the foreseeable future. Until clear incremental advantages can be demonstrated in well-constructed large trials, which should be available in the next few years, this may not change.
- References:
- Abell RG, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2014.06.025.
- Mastropasqua L, et al. J Cataract Refract Surg. 2014;doi:10.1016/j.jcrs.2014.05.032.
- Wu AM, et al. J Cataract Refract Surg. 2015;doi:10.1016/j.jcrs.2014.11.004.
- For more information:
- Richard B. Packard, MD, FRCS, FRCOphth, OSN Europe Edition Chairperson of the Editorial Board, can be reached at Arnott Eye Associates, 22a Harley St., London W1G 9BP, England; email: eyequack@vossnet.co.uk.
Disclosure: Packard has no relevant financial disclosures.