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Should ophthalmologists-in-training be allowed to use a femtosecond laser to assist in cataract surgery?
I was communicating with a colleague who was adamant that ophthalmology residents should not use a femtosecond laser to assist in cataract surgery since it would hinder the development of their manual skills. That's a reasonable argument, but I have a different perspective.
I think femto allows beginning surgeons, or those who are not as proficient at manual phacoemulsification, to achieve better results. For a more experienced or proficient surgeon, the benefits of femto phaco are less pronounced.
I absolutely love teaching cataract surgery to ophthalmology residents and, over the past dozen-plus years, I've had the pleasure of working with more than 100 ophthalmology residents from the Jules Stein Eye Institute at the UCLA Medical Center in Los Angeles on a weekly basis at a large county hospital separate from my private practice. This has involved thousands of cases with residents of all skill levels and just about every possible complication.
There is no question that the most difficult parts of cataract surgery for residents are rhexis creation and nucleus division – and these two steps have the toughest learning curves. Getting a resident to make a consistent rhexis (90% of the time or more) takes at least 100 cases. Learning phaco chop to my satisfaction may take even more.
With the femto, these beginning surgeons would be able to make a consistent rhexis and divide/soften the nucleus in more than 99% of cases. But yes, in difficult cases such as the small-pupil pseudoexfoliation lady on whom I did phaco this morning, manual skills still are needed. Nonetheless, I want all of my residents to have access to the femto laser for at least a few cases – enough to get a feel for the technology.
The femto laser has transformed some surgeons' practices in the community. For example, if a surgeon is primarily a LASIK surgeon but then she wants to get back into phaco, the femto would facilitate this. In another case, a surgeon who has difficulty with capsulorrhexis creation formerly did a can-opener capsulotomy for every phaco patient. Now he achieves better results with the femto capsulotomy.
I still teach manual extracapsular cataract surgery to all residents. While they may only do a few of them during residency, at least they've been exposed to it. I would also like them to do a handful of cases with a femto laser. And I'd like them to do a few LASIK cases, too. It is beneficial to have the residents exposed to as many technologies as possible, including femto.
We shouldn't be afraid of the new technology – our field is constantly evolving, and the way we will do cataract surgery 10 years from now will be different than the way we do it today.