Femtosecond laser-assisted surgery could revolutionize cataract removal around the world

After conquering the areas of refractive surgery and corneal grafting, the femtosecond laser has entered the realm of cataract surgery. It holds the promise of being a second revolution in cataract surgery, following the first revolution of Kelman’s phacoemulsification.

However, around the world, including in the Asia-Pacific region, cost and accessibility are concerns.

Zoltan Z. Nagy, MD, was the first surgeon in the world to perform femtosecond laser-assisted cataract surgery, which occurred at the University Hospital of Budapest, Hungary, in August 2008. He said phaco has gradually improved over the years, particularly in regard to incision size, but no major changes have been introduced.

“The femtosecond laser technology has brought new thoughts and methods in cataract surgery, and this is what we call a revolution,” he said.

Dr. Nagy was involved in the research and development team of the LenSx laser (Alcon) and has so far performed about 700 femtosecond-guided cataract procedures.

“I have seen the laser progress from the first prototype to the current technology. Within the various studies we’ve done with the laser, I have included about 30% to 40% of my cataract patients here, and I am still quite busy, with people coming from all over Europe, the U.S., Australia and South America,” he said.

In the Philippines, a LensAR femtosecond laser (LensAR/Topcon) has been available since November 2009 at the Asian Eye Institute in Manila. A second laser was recently acquired in the same city.

Image: Uy HS

“Patients know that it enhances precision and safety and come quite a long way to have cataract surgery done with it if they can afford the extra cost,” Harvey S. Uy, MD, director of research at the Asian Eye Institute, said. “Offering femtosecond laser cataract surgery is going to make a practice quite competitive.”

Dr. Uy has successfully treated 600 cases with this method.

Growing awareness, cost issues

Awareness of the availability and superior results of this new method of cataract surgery has rapidly increased. Internet-savvy patients have quickly become informed of the advantages of this technique and ask for it wherever femtosecond lasers are available.

“On my website, I published the news that I have the femtosecond for cataract surgery, and 3 days later, patients started asking to be operated with femtosecond,” Lucio Buratto, MD, OSN Europe Edition Associate Editor, said.

Patients generally tend to trust laser surgery more, he said, as it is perceived as less traumatic, painless, safer and more precise, in addition to having a faster recovery.

Dr. Buratto, director of a large private practice in Milan, was the second ophthalmologist in Europe to acquire a LenSx system and has so far treated about 60 cases. He has been using it since September 2011.

Cost, however, is an issue. Femtosecond laser-assisted cataract surgery is an expensive technique, and to date, no reimbursement scheme is provided by either national health systems or private insurances.

In the Philippines, phaco is considered an elective procedure and, in most cases, is paid for entirely by the patient, Dr. Uy said.

The cost of femtosecond laser-assisted cataract surgery is considerably higher in some Asia-Pacific countries, and only the wealthiest patients who are willing to pay a high price to have a premium procedure can afford it, he said.

Laser systems

There are currently four companies involved in the development of femtosecond laser technology for cataract surgery: Alcon, LensAR/Topcon, OptiMedica and Technolas Perfect Vision/Bausch + Lomb.

“Each one of these lasers has developed unique features to be competitive on the market,” Joseph Colin, MD, OSN Europe Edition Board Member, said. “LenSx and OptiMedica have integrated real-time OCT, providing complete visualization of the anterior segment during each phase of the procedure. The LensAR laser uses Scheimpflug imaging to register the ocular structures prior to laser activation. The LensAR and OptiMedica have a liquid optic interface that creates no pressure on the eye and provides comfortable docking and accurate acquisition of data for the imaging systems and laser. The Technolas laser is the first multitask platform that can be used for LASIK flap creation, cataract and therapeutic procedures.”

Dr. Colin and his colleagues at Bordeaux University Hospital, France, have been interested in the potential application in cataract surgery from the early years of femtosecond laser use and have developed their own laboratory prototype for research.

“We have not been able to acquire a proper femtosecond laser yet,” Dr. Colin said. “There are currently two of them in France, which were delivered in December last year to private practices.”

Advantages

The steps of cataract surgery that can be performed with the femtosecond laser are nucleus liquefaction/fragmentation, capsulorrhexis, corneal incision and, when needed, astigmatic relaxing incisions.

“We have been able to evaluate, in a large cohort of patients with a long follow-up, that there are significant advantages in performing the capsulorrhexis with femtosecond laser,” Dr. Nagy said. “We can guarantee the size and position of the rhexis and a perfect circumferential rhexis-optic overlap. This leads to perfect centration of the intraocular lens, leading to better visual quality, fewer or no problems with night vision, diplopia, myopic or hyperopic shift.”

Centration is particularly critical with premium implants, which can reach their full potential only when placed in a perfect anatomic position.

“It is definitely the option to offer to younger people who come for presbyopia. They want a premium lens and guaranteed results, and we can give this to them with femtosecond surgery,” Dr. Nagy said.

Higher predictability and reproducibility of both the rhexis and corneal incision steps are key features in favor of femtosecond laser procedures.

Pre-chopping the lens with the laser allows the surgeon to use less ultrasound. Dr. Nagy found that 42% less phaco energy and 51% less phaco time are used.

“In practical terms, it means that the aqueous temperature rise is less, leaving us with healthier endothelial cells after surgery,” he said.

Less ultrasound energy might also lead to a decreased rate of cystoid macular edema (CME), as demonstrated by Dr. Nagy in two studies.

“We need to extend these studies to more eyes, but it is likely that the less inflammatory mediator release and less mechanical trauma may lead to a decreased incidence of CME,” he said.

The surgeon can better predict the size and geometry of the corneal wound and make it uniplanar, biplanar, triplanar or multiplanar. Dr. Nagy performs biplanar incisions, which are self-sealing and carry no risk of infection.

“This allows me to pre-treat at least four patients outside the OR and then send them in turn to have phaco. At the end of surgery, because you have a very nice structured wound, you need no hydration,” he explained.

As for arcuate keratometry, the inbuilt OCT system allows the visualization and creation of a controlled corneal incision.

“Safety and refractive predictability are greatly increased,” Dr. Nagy said.

Restructuring surgical practices

Introducing the femtosecond laser in cataract surgery might require a new organization of patient flow, work space, clinic staff and appointment times. The best ways to make the new structure work efficiently are still a matter of debate.

“Typically, in most surgical centers worldwide, the new laser is kept outside the OR, but both the laser and phaco stages are performed by one surgeon. Other more efficient solutions, like having specialized non-medical personnel do the femtosecond stages, might be possible in the future,” Dr. Colin said.

At the University Hospital of Budapest, the femtosecond laser has been installed in a dedicated room, Dr. Nagy said.

“We had so many times the technicians around to study, service and upgrade the laser over these years that it was definitely not feasible to have it in the operating room. Also, the operating room is used by many other surgeons, and we don’t want to make it too crowded,” he said.

He is personally involved in all stages of the procedure, he said.

Dr. Uy operates in a large ambulatory surgical center with four operating rooms. He said the laser is kept in one room and the patient is then moved to another room. So far, Dr. Uy has taken care of all patients at all stages of the procedure, and he is now training other surgeons to use the technique.

“We have gradually improved the efficiency of the procedure, and we are basically performing femtosecond laser cataract surgery in no more than 20 minutes per patient,” he said.

Future possibilities

In the Asia-Pacific region, according to Dr. Uy, there is a wide variety of possible scenarios for the future of femtosecond laser-assisted cataract surgery.

“Where public reimbursement is little or none, the technology is still likely to expand in the private sector. I expect that more and more centers will acquire the laser. Offering this new technique will give them competitive advantages, as they will be perceived as able to offer premium services and better results,” he said.

On the other hand, in countries where universal health care has been implemented, the citizens themselves will most likely put pressure on governments to provide this service as part of the national health care program.

Although convinced that femtosecond technology is a step forward in cataract surgery, Dr. Colin cautioned the ophthalmic community from the danger of “running too fast for fear of missing the train.”

“The risk is that of making huge investments in the technology because we are worried about the competition rather than because we are truly convinced of the advantages of the laser,” he said. “If these advantages are real and worth investing in, if the transition from phaco to femto is the step we should make, only further studies can show. We should wait for these results, and not precipitate decisions.” – by Michela Cimberle

References:

Buratto L, Global Market Intelligence, Alcon Inc. A 45 minute online questionnaire to cataract surgeons in France, Germany, Italy and Spain. 2010-2011.

Chatoux O, Touboul D, Buestel C, Balcou P, Colin J. Crystalline lens photodisruption using femtosecond laser: experimental study. J Fr Ophtalmol. 2010;33(7):472-480.

Ecsedy M, Miháltz K, Kovács I, Takács A, Filkorn T, Nagy ZZ. Effect of femtosecond laser cataract surgery on the macula. J Refract Surg. 2011;27(10):717-722.

Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011;37(7):1189-1198.

He L, Sheehy K, Culbertson W. Femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol. 2011;22(1):43-52.

Kránitz K, Takacs A, Miháltz K, Kovács I, Knorz MC, Nagy ZZ. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011;27(8):558-563.

Mamalis N. Femtosecond laser: the future of cataract surgery? J Cataract Refract Surg. 2011;37(7):1177-1178.

Masket S, Sarayba M, Ignacio T, Fram N. Femtosecond laser-assisted cataract incisions: architectural stability and reproducibility. J Cataract Refract Surg. 2010;36(6):1048-1049.

Miháltz K, Knorz MC, Alió JL, et al. Internal aberrations and optical quality after femtosecond laser anterior capsulotomy in cataract surgery. J Refract Surg. 2011;27(10):711-716.

Moshirfar M, Churgin DS, Hsu M. Femtosecond laser-assisted cataract surgery: a current review. Middle East Afr J Ophthalmol. 2011;18(4):285-291.

Nagy ZZ, Kránitz K, Takacs AI, Miháltz K, Kovács I, Knorz MC. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg. 2011;27(8):564-569.

Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Refract Surg. 2009;25(12):1053-1060.

Naranjo-Tackman R. How a femtosecond laser increases safety and precision in cataract surgery? Curr Opin Ophthalmol. 2011;22(1):53-57.

Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laser-assisted cataract surgery with integrated optical coherence tomography. Sci Transl Med. 2010;2(58):58-85.

Roberts TV, Sutton G, Lawless MA, Jindal-Bali S, Hodge C. Capsular block syndrome associated with femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2011;37(11):2068-2070.

Uy HS, Edwards K, Curtis N. Femtosecond phacoemulsification: the business and the medicine. Curr Opin Ophthalmol. 2012;23(1):33-39.

For more information:

Lucio Buratto, MD, can be reached at Centro Ambrosiano di Microchirurgia Oculare (CAMO), Piazza Repubblica 21, 20124 Milan, Italy; +39-02-6361191; fax: +39-02-6598875; email: office@buratto.com.

Joseph Colin, MD, can be reached at Hôpital Pellegrin, Place Amélie Raba-Lèon, 33076 Bordeaux, France; +33-5-56795608; fax: +33-5-56795909; email: joseph.colin@chu-bordeaux.fr.

Zoltan Z. Nagy, MD, can be reached at Semmelweis University Eye Hospital, Maria Street Unit 39, H-1085 Budapest, Hungary; +36-20-815-8468; email: nagy.zoltan_zsolt@med.semmelweis-univ.hu or zoltan.nagy100@gmail.com.

Harvey S. Uy, MD, can be reached at Asian Eye Institute, 9F Phinma Plaza Building, Rockwell Center, Makati, Philippines; +63-2-4166782; email: harveyuy@yahoo.com.

Disclosures: Dr. Buratto and Dr. Colin have no relevant financial disclosures. Dr. Nagy is a consultant for Alcon LenSx. Dr. Uy is an investigator for LensAR and a member of the local advisory board of Alcon.

 

 

Do you think femtosecond lasers will eventually make phacoemulsification an obsolete technique?

Potential of femtosecond technology will be realized

It is certain that femtosecond lasers will replace phaco technology.

How long this takes to occur is debatable. It will happen faster for some surgeons, depending on their patient population and the type of cataracts they generally deal with.

When research began on the femtosecond cataract work station, the starting point was based on the maneuvers inherent in traditional phacoemulsification. So, hydrodissection and four quadrant cracking were a place to start. With this approach, phaco time and energy are approximately halved. In the last year, we have seen techniques evolve to a variety of patterns and shapes to allow easier nucleus disassembly with a resultant further decrease in phaco time and energy. Hydrodissection has been eliminated by some surgeons.

What we do is relatively primitive at present. As surgeons explore patterns, depth levels and targeted disassembly to specific types of cataract, we will find phaco energy will become minimal, then unnecessary. Some patients with very small pupils, corneal scars, etc., will never be suitable for femtosecond surgery, so my comments relate to patients in whom technical suitability is assumed.

At this stage, femtosecond laser technology for cataracts is like being given a new laptop and starting to explore its potential. Once that potential is realized, phacoemulsification will become obsolete in cataract surgery.

 

Michael Lawless, MD, is an OSN APAO Edition Associate Editor. Disclosure: Dr. Lawless is on the medical advisory board of Alcon/LenSx.

Intrinsic limitations to femtosecond laser will not be overcome

The transition from ECCE to phaco, from removal of the whole lens to fragmentation and aspiration of the lens nucleus, was indeed a revolution. No revolutionary concepts have been introduced by the femtosecond laser in cataract surgery, just a new technology. The laser performs some of the maneuvers that the surgeon routinely performs. It is a complementary technique, not an alternative, because phaco is still necessary.

The capsulorrhexis is well-centered but not continuous. The femtosecond laser does not produce a continuous cut, but a row of micro-explosions. It is a revisited, more refined can-opener technique, which cannot achieve the same resistance to tear as a continuous rhexis performed manually with a needle or forceps.

When I perform the incision manually, I have an immediate feeling of the length, depth and angle that is best for each eye. The decision-making process is one with the surgical maneuver. Femtosecond laser incisions take into account that all eyes are different, but they require a time-consuming preoperative evaluation of the eye and setting of the laser.

Last but not least, the laser beam needs a transparent target, and nucleus fragmentation can therefore be performed with cataracts that are hardly worth operating on. With most old age cataracts, the laser will not work at this stage. With complicated cataract cases, your surgical ability and your old phaco machine will help, not the laser.

In other words, in simple cataract cases, the laser does nothing more than the surgeon can do and does it in at least double the time with cumbersome changes of rooms, beds and patient positions. In complicated cataract cases, or simply with denser cataracts, the laser is not an option. There are limitations that are intrinsic to the femtosecond laser and will not be overcome, no matter how much the technique evolves.

 

Alessandro Galan, MD, is an OSN Europe Edition Board Member. Disclosure: Dr. Galan has no relevant financial disclosures.