Eyeworld

EW REFRACTIVE 26 February 2019 Refractive roundtable capsulotomy and what it did for my refractive outcomes. But when the Chang and Waring paper came out on the Purkinje method of centering the capsulotomy with the subject- fixated coaxially sighted corneal light reflex and I started using that in my monofocal patients with an optical zone marker with the patient fixating, I was getting a higher rate of 360 degrees of capsular overlap manually. 1 I started to wonder about the value proposition of continuing to do femto. Then I started using the Zepto (Mynosys Cellular Devices, Fremont, California) method with the Purkinje method and I also got nice capsular overlap at a higher rate than manual. 2 I think if femto can move back into the OR and with OCT guidance we get a high degree of 360 degree overlap, we'll see its use increase. Dr. Vukich: That raises a good ques- tion. Femtosecond lasers do four things. They create an incision, cre- ate limbal relaxing incisions, create a capsulotomy, and can soften the lens. Which of those features do you think adds the greatest value when you use those for patients? Dr. Waring: I would rank it in terms of capsulotomy, pre-chopping/soft- ening, then LRI. Another thing that parameters. Now we are only doing the capsulotomy with the cylinder inside, and that improved much of the reaction of the pupil. Dr. Dell: As these devices become better, smaller, and faster, and it becomes possible for them to live in the OR entirely, how does that rec- oncile with the notion that a second shooter in a second location is the ideal state? Dr. Nehls: You may not need that. Dr. Dell: Right, if you had it inte- grated into your phaco machine and microscope and it was quick and easy, and you could do it right there. For those who don't have a fellow doing their cases, there is a cost associated with having a dedicated second surgeon doing cases during the day. Basically two people to do one person's job now. How do you reconcile what seem to be compet- ing forces? Dr. Thompson: You bring up a good point. I think if femto can evolve to that, we'll see femto use increase. Right now, femto use has plateaued and people are discuss- ing why. For me, early on, I found great value in it. I was fine taking the extra time, and it taught me so much about the well-rounded with the use of the femtosecond laser in your practice? Dr. Nehls: I think it is ideal to have a partner assist in femto cases, the "shooter." It would slow a surgeon down to be doing femto surgery for the duration of all cases. In my academic setting, once our fellow is trained, that's who does the femto cases while I am in the OR removing cataracts. Overall, my efficiency is the same or a little better. Dr. Vukich: Where do you keep your laser? Is it in your OR or in a separate room? Dr. Nehls: It's in what used to be a preop room, right next to the OR. Dr. Williamson: We have a laser suite adjacent to our OR and that's where my shooter is. He does all of my monofocals with astigmatism correction and I do the advanced technology IOLs. Dr. Zaldivar: There is a timing issue here because if you wait awhile after the procedure to do the surgery, the pupil sometimes starts getting smaller. There is a perfect timing and you have to finish from the prior procedure and get to the operating room. Another thing that we im- proved is that we change a lot of the The conclusion of a discussion among leaders in refractive surgery from the 2018 ASCRS•ASOA Annual Meeting During the 2018 ASCRS•ASOA Annual Meeting, John Vukich, MD, surgical director, Davis Duehr Dean Centre for Refractive Surgery, Madison, Wisconsin, and Vance Thompson, MD, Vance Thompson Vision, Sioux Falls, South Dakota, moderated a discussion on whether femto laser-assisted cata- ract surgery adds value to a premium practice. The participants were Roger Zaldivar, MD, Instituto Zaldivar, Mendoza, Argentina, Blake William- son, MD, Williamson Eye Center, Baton Rouge, Louisiana, George Waring, MD, Waring Vision Institute, Mt. Pleasant, South Carolina, Steven Dell, MD, Dell Laser Consultants, Austin, Texas, Thomas Clinch, MD, Eye Doctors of Washington, Chevy Chase, Maryland, and Sarah Nehls, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. This is an edited transcript of the second part of the discussion. The first half appeared in the January 2019 issue of EyeWorld. Dr. Vukich: Are there any tips you can share on achieving efficiency Part 2: Does femtosecond laser-assisted cataract surgery add value to a premium practice? continued on page 29 Dr. Vukich Dr. Thompson Dr. Zaldivar Dr. Williamson Dr. Waring Dr. Dell Dr. Clinch Dr. Nehls

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