EDITORIAL
Femtosecond Laser: Is It the Way Forward for Cataract Surgery? Srinivas K. Rao, FRCS,* Vishal Jhanji, MD,Þ and Alex H. Fan, FRCSÞ
T
aking into consideration that cataract surgery is the most commonly performed surgical procedure in ophthalmology, it is not surprising that efforts are constantly made to improve its safety and efficacy. The shift from manual extracapsular cataract extraction to mechanized, ultrasound-assisted, small-incision cataract surgery has now been achieved, which has resulted in enormous benefits to patients. Such benefits have been achieved at a fair costVto both the patient in terms of the cost of the procedure and the surgeon who has to learn new skills. On the negative side, young ophthalmologists now learn phacoemulsification as the primary surgical skill for cataract surgery and may therefore have limited skills with regard to ocular wound construction and sutured closure. If we analyze the benefits of the procedural shift, we find that these accrue largely from the following: the use of a small, standardized incision, the creation of a lens bag (which was not possible with a beer-can capsulotomy), and the sequestration of the intraocular lens (IOL) with minimal uveal contact. Building on these advances, newer types of IOLs have further increased the accuracy of the procedure by adding toricity and multifocality to the IOL design, which was simply impossible in the era of large, sutured incisions and sulcus placement of the IOL. Phacoemulsification thus allowed major paradigm shifts compared to manual extracapsular cataract extraction. Refractive surgery, the other commonly performed surgical procedure, has also seen a similar paradigm shift. The use of the excimer laser improved the precision with which corneal tissue was removed, but wound healing affected outcomes when photorefractive keratectomy (PRK) was performed. The addition of a microkeratome to create a corneal flap resulted in dramatic improvements in efficacy - although it also led to problems, some of which like ectasia were recognized some years after the popularity of the procedure resulted in increased numbers being performed. The use of the femtosecond laser to create a flap has many advantages, including the increased precision of the laser, and the reduction in some of the problems associated with mechanical microkeratomes. Despite its advantages, widespread use of the femtosecond laser has not been found. While there are very few centers performing PRK, many refractive centers still use the microkeratome. Although the reasons for this are many, it can be primarily explained by the additional cost the use of the femtosecond laser entails. The patient will have to pay more per procedure and so will the surgeon when providing such service. It may also have something to do with the fact that the laser performs only 1 step of the procedure while the rest of the stepsVfrom raising the flap to performing a precise refraction and centered ablation and managing the flapVremain as before. Experienced surgeons, whose microkeratome skills are good, may not perceive added benefits to having the femtosecond in their practice, unless they are convinced that their patient numbers and perspective will support the economics of this laser addition. Hence, while reduction in costs of the equipment over time may result in more femtosecond installations, it does not seem probable at this time that femtosecond refractive surgery will replace current microkeratome LASIK, as completely as LASIK eclipsed PRK. Drs Lawless and Hodge1 have written about their experience with the femtosecond laser for cataract surgery in Australia during the past 6 months and have highlighted many of the relevant issues with regard to this topic. Because the femtosecond laser performs some of the steps of cataract surgery, and the surgeon will then have to take recourse to traditional phacoemulsification to complete the procedure, the scenario is much like what is described in the previous paragraph regarding the refractive experience. With cataract surgery, the use of the femtosecond laser to perform some of the steps is likely to enhance the safety of the procedure more in the hands of neophyte surgeons and less for experienced phaco surgeons. Unfortunately, it is also less likely that neophyte surgeons will have access to these machines in their practice because of cost concerns and logistic issues. While the precision of steps of surgery is definitely enhanced with the use of the femtosecond laser, whether endophthalmitis will reduceVgiven that most of the time, the organisms are introduced
From the *Darshan Eye Clinic and Surgical Centre, Tamil Nadu, India; and †Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong. Reprints: Srinivas Rao, MD, Darshan Eye Clinic and Surgical Centre. E-mail: [email protected]. The authors report no conflicts of interest. Copyright * 2012 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e31824228a1
Asia-Pacific Journal of Ophthalmology
&
Volume 1, Number 1, January/February 2012
www.apjo.org
Copyright @ 2011 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
3
Asia-Pacific Journal of Ophthalmology
Editorial
during surgeryVremains a moot point. Similarly, until IOLs are available in steps smaller than 0.5D, the benefits of a more circular and more central capsulorhexis are unlikely to be fully realized. The debate about the relative merits of the femtosecond cataract procedure is likely to heat up in the coming months and years as more surgeons are likely to be using these systems. However, the perceived increase in safety and efficacy will definitely come at a fairly high cost, and whether the procedure
&
Volume 1, Number 1, January/February 2012
will take over cataract surgery, much as phacoemulsification has done before, remains to unfold. The coming years promise to be interesting and exciting for ophthalmologists and cataract and refractive surgeons. REFERENCE 1. Lawless M, Hodge C. Femtosecond laser cataract surgery: an experience from Australia. Asia Pac J Ophthalmol. 2012;1:5Y10.
Employ your time in improving yourself by other men’s writings, so that you shall gain easily what others have labored hard for.
4
www.apjo.org
* 2012 Asia Pacific Academy of Ophthalmology
Copyright @ 2011 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
Femtosecond Laser: Is It the Way Forward for Cataract Surgery? Srinivas K. Rao, FRCS,* Vishal Jhanji, MD,Þ and Alex H. Fan, FRCSÞ
T
aking into consideration that cataract surgery is the most commonly performed surgical procedure in ophthalmology, it is not surprising that efforts are constantly made to improve its safety and efficacy. The shift from manual extracapsular cataract extraction to mechanized, ultrasound-assisted, small-incision cataract surgery has now been achieved, which has resulted in enormous benefits to patients. Such benefits have been achieved at a fair costVto both the patient in terms of the cost of the procedure and the surgeon who has to learn new skills. On the negative side, young ophthalmologists now learn phacoemulsification as the primary surgical skill for cataract surgery and may therefore have limited skills with regard to ocular wound construction and sutured closure. If we analyze the benefits of the procedural shift, we find that these accrue largely from the following: the use of a small, standardized incision, the creation of a lens bag (which was not possible with a beer-can capsulotomy), and the sequestration of the intraocular lens (IOL) with minimal uveal contact. Building on these advances, newer types of IOLs have further increased the accuracy of the procedure by adding toricity and multifocality to the IOL design, which was simply impossible in the era of large, sutured incisions and sulcus placement of the IOL. Phacoemulsification thus allowed major paradigm shifts compared to manual extracapsular cataract extraction. Refractive surgery, the other commonly performed surgical procedure, has also seen a similar paradigm shift. The use of the excimer laser improved the precision with which corneal tissue was removed, but wound healing affected outcomes when photorefractive keratectomy (PRK) was performed. The addition of a microkeratome to create a corneal flap resulted in dramatic improvements in efficacy - although it also led to problems, some of which like ectasia were recognized some years after the popularity of the procedure resulted in increased numbers being performed. The use of the femtosecond laser to create a flap has many advantages, including the increased precision of the laser, and the reduction in some of the problems associated with mechanical microkeratomes. Despite its advantages, widespread use of the femtosecond laser has not been found. While there are very few centers performing PRK, many refractive centers still use the microkeratome. Although the reasons for this are many, it can be primarily explained by the additional cost the use of the femtosecond laser entails. The patient will have to pay more per procedure and so will the surgeon when providing such service. It may also have something to do with the fact that the laser performs only 1 step of the procedure while the rest of the stepsVfrom raising the flap to performing a precise refraction and centered ablation and managing the flapVremain as before. Experienced surgeons, whose microkeratome skills are good, may not perceive added benefits to having the femtosecond in their practice, unless they are convinced that their patient numbers and perspective will support the economics of this laser addition. Hence, while reduction in costs of the equipment over time may result in more femtosecond installations, it does not seem probable at this time that femtosecond refractive surgery will replace current microkeratome LASIK, as completely as LASIK eclipsed PRK. Drs Lawless and Hodge1 have written about their experience with the femtosecond laser for cataract surgery in Australia during the past 6 months and have highlighted many of the relevant issues with regard to this topic. Because the femtosecond laser performs some of the steps of cataract surgery, and the surgeon will then have to take recourse to traditional phacoemulsification to complete the procedure, the scenario is much like what is described in the previous paragraph regarding the refractive experience. With cataract surgery, the use of the femtosecond laser to perform some of the steps is likely to enhance the safety of the procedure more in the hands of neophyte surgeons and less for experienced phaco surgeons. Unfortunately, it is also less likely that neophyte surgeons will have access to these machines in their practice because of cost concerns and logistic issues. While the precision of steps of surgery is definitely enhanced with the use of the femtosecond laser, whether endophthalmitis will reduceVgiven that most of the time, the organisms are introduced
From the *Darshan Eye Clinic and Surgical Centre, Tamil Nadu, India; and †Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong. Reprints: Srinivas Rao, MD, Darshan Eye Clinic and Surgical Centre. E-mail: [email protected]. The authors report no conflicts of interest. Copyright * 2012 by Asia Pacific Academy of Ophthalmology ISSN: 2162-0989 DOI: 10.1097/APO.0b013e31824228a1
Asia-Pacific Journal of Ophthalmology
&
Volume 1, Number 1, January/February 2012
www.apjo.org
Copyright @ 2011 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
3
Asia-Pacific Journal of Ophthalmology
Editorial
during surgeryVremains a moot point. Similarly, until IOLs are available in steps smaller than 0.5D, the benefits of a more circular and more central capsulorhexis are unlikely to be fully realized. The debate about the relative merits of the femtosecond cataract procedure is likely to heat up in the coming months and years as more surgeons are likely to be using these systems. However, the perceived increase in safety and efficacy will definitely come at a fairly high cost, and whether the procedure
&
Volume 1, Number 1, January/February 2012
will take over cataract surgery, much as phacoemulsification has done before, remains to unfold. The coming years promise to be interesting and exciting for ophthalmologists and cataract and refractive surgeons. REFERENCE 1. Lawless M, Hodge C. Femtosecond laser cataract surgery: an experience from Australia. Asia Pac J Ophthalmol. 2012;1:5Y10.
Employ your time in improving yourself by other men’s writings, so that you shall gain easily what others have labored hard for.
4
www.apjo.org
* 2012 Asia Pacific Academy of Ophthalmology
Copyright @ 2011 Asia Pacific Academy of Ophthalmology. Unauthorized reproduction of this article is prohibited.
