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Does femtosecond-assisted cataract surgery threaten job security for cataract surgeons?
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By now, most of us have heard that femtosecond lasers are being developed to assist in cataract surgery. The U.S. Food and Drug Administration has already granted 510(k) clearance for creation of anterior capsulotomies. Currently three (maybe more) companies are pursuing this technology: OptiMedica, LenSx and LensAR.
 Using microforceps, a surgeon removes the capsular remnant created after a circular capsulotomy made by a femtosecond laser. (Image courtesy of LensAR, Inc.) |
It has been proposed that these lasers, in addition to creating highly precise corneal incisions, can "soften" the nucleus of the lens by disrupting the lens tissue within the capsule. They can then make a perfectly round, perfectly centered capsulotomy. The surgeon's role, then, would be to open the already created incision, pull away the anterior capsule remnant, vacuum out the nucleus and place an implant.
Some have guessed that the availability of this technology will simplify cataract surgery to the point that technicians with limited training will be able to do the procedure — that we just won't need cataract surgeons any more.
That's quite unlikely.
It's true, femtosecond lasers can standardize some steps in surgery. Having a highly predictable capsule opening will probably improve the predictability of IOL position and refractive outcome. It will also simplify our lives for IOLs of the future, such as the Visiogen (now Abbott Medical Optics) Synchrony, which demands a just-so capsulotomy, or lens-filling technologies. Softening the nucleus will also reduce phaco energy. That means faster surgery, less fluid and quicker postoperative rehabilitation.
But what about eyes with dense cortical opacity? Femtosecond lasers cannot penetrate beyond white anterior opacity. A morgagnian cataract will (for now) remain the surgeon's challenge to remove.
Femtosecond lasers also can't do cortical cleanup for us — one of the steps most likely to cause capsular breakage. You need an experienced surgeon for that.
Small pupil? Posterior synechiae? Floppy iris? Pseudoexfoliation? How will a machine make it possible for an inexperienced human to tackle these? Score more points for the good guys.
Lastly, no laser device can or will substitute for the on-the-fly judgment that cataract surgeons use to handle the many surprises that occur on our OR days.
Femtosecond lasers are indeed likely to change the way we think about cataract surgery, opening a host of possibilities for new technologies that require greater precision than our hands can deliver. For now, though, we surgeons can still plan on showing up on surgery day with our game faces on for a good number of years to come.
Get more expert perspective from Dr. Hovanesian live at Hawaiian Eye 2010, to be held January 17-22, 2010 at the Grand Hyatt Kauai. Learn more at OSNHawaiianEye.com.