Q&A: SLACS and the advantages of having both laser and phaco in the operating room
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Key takeaways:
- Sterile laser-assisted cataract surgery expands the advantages of femtosecond laser-assisted cataract surgery.
- The procedure is performed in one sterile setting without moving the patient.
Sterile laser-assisted cataract surgery, or SLACS, is the new frontier of minimally invasive femtosecond laser-assisted cataract surgery.
The procedure can be performed in one setting under sterile conditions without moving the patient from place to place. It also expands the advantages of femtosecond laser-assisted cataract surgery (FLACS) by allowing the surgeon to more efficiently use the laser intraoperatively as a surgical tool.
To learn more about this approach, Healio interviewed Wendell J. Scott, MD, who trademarked the term SLACS, and H. Burkhard Dick, MD, PhD, a pioneer of FLACS.
Healio: From FLACS to SLACS: What are the gains?
Scott: SLACS is distinct from FLACS because it is performed under sterile conditions in the operating room, whereas FLACS is performed as a pre-surgery, nonsterile procedure in a treatment room. By performing the laser in the operating room with SLACS, the surgeon can switch from the laser to the operating microscope without any delay. Problems previously noted, such as miosis after the laser when there is a delay moving the patient to surgery, are eliminated. This allows the surgeon to use the laser as a “tool” in surgery that can improve efficiency and outcomes as well as perform surgical procedures that are otherwise not possible.
Dick: If the laser is used in the operating room, you can use it as a surgical tool. You can use it intraoperatively, for example, to perform primary posterior laser-assisted capsulotomy, a great technique published by our group that has the potential to prevent and solve posterior capsule opacification. You can also perform the rescue technique as well as my absolute favorite, the so-called mini-capsulotomy technique, in which a small capsulotomy is performed in mature intumescent cataracts to release the intralenticular pressure, making the case easier. You can also use the laser for phakic IOL explantation. Lasing with the phakic lens in the eye is riskier than doing it after the phakic lens has been removed, while removing the lens first makes the entire cataract procedure much easier and safer. Finally, if you are opening the eye, you have to do this in the OR under sterile conditions. That means that the main incision and the paracentesis can be performed with the femtosecond laser but in the OR.
Healio: How is your OR organized for SLACS, and how do you optimize patient flow with this procedure?
Scott: We utilize two operating rooms per surgeon. We call that a “flip room,” flipping from one room to the next, where the patient is already positioned and has been prepped and draped. I am currently using the Catalys (Johnson & Johnson Vision), and we have three ORs and three lasers, allowing our five surgeons at Mercy in Springfield, Missouri, to treat all patients with SLACS. We do the laser portion of the procedure and then rotate the bed under the microscope to perform phacoemulsification. Usually, the laser portion of the procedure is 1 to 2 minutes, and there are 30 to 60 seconds on average from when we finish the laser to when we start the surgery. Because the lens has been pre-fragmented with the laser, the phacoemulsification portion of the procedure is also shortened.
Dick: The laser is positioned so that both sides of the eye can easily be assessed and the surgeon sits comfortably. The microscope is arranged so that it is close to the laser. The patients stay in one place, and this is the first important optimized point. They are not moved, and a certified doctor is doing the preparation as well as the lasing. I step in just for the lens part of the surgery, which means that my surgical time is tremendously reduced. My preoperative digital diagnostics are connected with the OR, so we have lens calculation, tomography and every other parameter at a glance, together with the biomorphometric intraoperative registration of iris features and precise laser marking for toric IOLs. We have the Catalys, the Lensar and the Ziemer Z8 for cataract surgery in our clinic. The new laser systems have a smaller footprint, and they are now mobile and offer a separate bed that is not attached to the laser. This allows great patient flow and faster throughput per day.
Healio: What is the cost-benefit balance?
Scott: The biggest benefit is the contribution to better outcomes and patient satisfaction. There is an additional cost to using the laser, but that cost can be offset by increasing patient volumes and cash flow for premium procedures. Patient satisfaction has increased, as shown by satisfaction surveys before laser and after laser cataract surgery. We are a big vertical health system with lots of different specialties, and our center consistently has the highest patient satisfaction score in the entire system. This has been a result of being able to standardize the process. Patients understand that they are getting the best technology and the best personalized care.
Dick: With the laser in the OR, there is no flow disruption from patients going to room one and then to room two and maybe room three. And the heating, ventilating, air conditioning and cooling systems are also there, maintaining the controlled environment that is needed for the femtosecond laser. There is also less human power involved because patients do not have to be moved from room to room and have to stand up and sit down and lay down again. That means you have the possibility to do more surgeries per day. The surgical time for the surgeon is greatly reduced if the laser is in the OR, and that means you can offer an increased number of options to the patients. Some systems are now beginning to incorporate a phaco machine within the laser platform.
For more information:
H. Burkhard Dick, MD, PhD, of the University Eye Hospital Bochum in Germany, can be reached at dickburkhard@aol.com.
Wendell J. Scott, MD, of Mercy Hospital in Springfield, Missouri, can be reached at wendell.scott@mercy.net.
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