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Low-energy FLACS induces prostaglandin increase
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Low-energy femtosecond laser-assisted cataract surgery induced significantly higher levels of prostaglandin E2 during surgery than conventional phacoemulsification, according to a study.
Furthermore, in eyes pretreated with NSAIDs before FLACS, prostaglandin levels were significantly less perioperatively than in eyes that did not undergo pretreatment. However, the difference was not statistically significant between the two postoperatively.
“The use of topical NSAIDs with a low-energy femtosecond laser reduced prostaglandins levels to the same as in the conventional group. This is not the same with high-energy lasers,” co-author Jodhbir S. Mehta, BSc, MBBS, PhD, FRCOphth, FRCS (Ed), FAMS, of Singapore National Eye Centre, told Healio.com/OSN.
Seventy patients were included in a randomized controlled trial evaluating the aqueous oxidative stress, prostaglandin E2 (PGE2) and cytokine levels after low-energy femtosecond laser-assisted cataract surgery compared with conventional phacoemulsification. The effect of NSAID treatment on the aqueous profiles was also evaluated.
In one cohort, 35 patients underwent conventional phacoemulsification in one eye and femtosecond laser-assisted cataract surgery with the Femto LDV Z8 (Ziemer) in the fellow eye. Another cohort of 35 patients was pretreated with NSAIDs before undergoing femtosecond laser-assisted cataract surgery in one eye.
The PGE2 levels increased after phacoemulsification in all eyes compared with before the procedure. After phacoemulsification, PGE2 levels increased by 87.9% in the conventional group, 44% in the femtosecond-assisted group and 67% in the femtosecond-assisted NSAID group.
“Unexpectedly, at the end of surgery, the prostaglandin level was higher in all groups, despite copious [balanced salt solution] irrigation and aspiration, meaning that the preoperative use of drops is only protective before surgery and patients should start anti-inflammatory drops immediately after surgery,” Mehta said.
However, NSAIDs did reduce the PGE2 surge and the rate of intraoperative miosis, according to the study.
Aqueous malondialdehyde levels were increased in all eyes, with greater phacoemulsification time correlated with greater increase (P < .002). Preoperative NSAID treatment did not suppress the increase. – by Robert Linnehan
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Beeran Meghpara, MD
The benefit of femtosecond laser-assisted cataract surgery (FLACS) is one of the most hotly debated topics among cataract surgeons today. Those who are “pro-femto” argue a potential decrease in endothelial cell loss, more accurate astigmatism correction and a perfectly circular well-centered capsulorrhexis outweigh potential downsides. “Anti-femto” surgeons cite decreased efficiency, increased cost and a potentially higher complication rate as reasons why they have not adopted this technology.
The increased prostaglandin surge after FLACS is another major issue surgeons worry about. This can potentially increase the risk for postoperative cystoid macular edema. Additionally, this increased prostaglandin level may contribute to the increased rate of intraoperative miosis we see in FLACS.
Several previous studies have confirmed a prostaglandin surge following FLACS using high-energy laser platforms such as the Catalys (Johnson & Johnson Vision) and LenSx (Alcon). Those who prefer the lower-energy Femto LDV Z8 (Ziemer Ophthalmic Systems) laser platform may be hoping the surge is less.
This randomized controlled study shows that prostaglandin levels are elevated after FLACS, both before and after phacoemulsification using the low-energy platform compared with the conventional phacoemulsification group. This study also reports preoperative NSAID drops decrease the prostaglandin rise to levels comparable to conventional phacoemulsification. This effect of NSAIDs, however, was studied in a separate cohort of patients. It would be interesting to see a randomized controlled study in which patients undergoing FLACS in both eyes receive preoperative NSAIDs in one eye and no pretreatment in the fellow eye.
Preoperative NSAIDs were also found to decrease the amount of intraoperative miosis. This is consistent with what we see clinically in our practice, where we regularly pretreat all eyes with topical NSAIDs before FLACS. Furthermore, we give an additional drop of NSAID after laser treatment to help combat the issue of miosis.
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