Eyeworld

29 EW REFRACTIVE it brings to the table is image guid- ance. We now do 90% of our cases with femto, so I'm looking before I walk into the OR to see exactly what we're dealing with and I get a lot of information from doing that. Is it absolutely necessary? No, but do I think it makes me better equipped and understand the patient's eye better? Yes. We've gone on to ana- lyze the biometrics of this and we're learning a lot that's challenging the way we think on how eyes behave. Dr. Clinch: When you ask to pri- oritize, I think it does an injustice. To me, it is the fact that it has all of these attributes that makes femto- second cataract surgery superior. In some patients, the phacolysis is the main advantage; for others, it is the precision of the capsulotomy. This is especially true with toric IOLs where capsule overlap is critical. For dif- fractive IOLs, the ability to place ac- curate corneal incisions to minimize astigmatism improves the range of visual function. I find in different patients, it has different attributes and that's why we use a femtosec- ond laser on the vast majority of our premium patients. Dr. Vukich: For certain patients we have this package of options and we represent that the laser will be used, but occasionally we can't do these laser components of the surgery. How do you discuss that with the patient? Dr. Waring: We treat this a lot like LASIK and PRK. If we have an orbital anatomy that may not lend itself well to a coupling device and a pa- tient interface, we will usually pick up on that in the exam lane and we'll document that we may not be able to successfully do the laser. Then we'll always remind them as they're on the table that I'll give it three tries, we've got a lot of tricks we can utilize, but if we can't do it, we're going to do it like we always did without laser and they're going to be fine. Dr. Nehls: I think it is very rare though that you can't get a patient to dock through the entire treat- ment. The docking systems have improved with some steeper fits and flatter fits for the corneal surface. Dr. Williamson: I haven't had one patient in the past 18 months that I've been using this that I haven't at least been able to do part of the procedure on. What's good about the laser that we use is you can turn different parts off. If the pupil is too small, I won't be performing the capsulotomy, but I'll be able to do some segmentation, I'll be able to treat the astigmatism. Dr. Clinch: Patients don't come to a surgeon specifically because they utilize a laser. Patients make their choice based on confidence and trust. I counsel patients that we're going to try to utilize all available technologies; however, it doesn't necessarily mean that we can use every option in each case. Dr. Vukich: There has been a lev- eling off of the number of FLACS procedures that are being performed. Practices are doing more but in general the number of placements of new machines has leveled off or even started to slightly decline. For those who are active users and are seeing great value in the practice, I wonder what you might attribute that to and how that might turn around? Dr. Clinch: It is a challenge to provide premium cataract surgery. It requires careful review of every as- pect of your practice infrastructure. Some doctors are reluctant to move toward a laser platform because they are uncomfortable with their refractive outcomes. At times, all of us have been humbled by refractive outliers. As surgeons become more comfortable with newer IOL cal- culation formulas and can reliably deliver a better product, there will be greater utilization of femtosecond technology to fine tune the process. Dr. Nehls: I think it will also change in the next 5–10 years as trainees come out of their programs and are using it because they trained with it and like it. I think that is going to change the use of FLACS. Dr. Thompson: As we come to the end of our discussion, would you like to share any parting comments? Dr. Williamson: I wasn't practicing during the days of microkeratome and certainly not extracap, but analogies can be made to when we went from extracap to phaco or microkeratome LASIK to femto LASIK in the sense that the data went from being underwhelming to good to overwhelming. I think that as the technology improves and as surgeons improve and learn how to use this, femto cataract may follow a similar trajectory, but for the time being one thing that I would say is to focus on what the technology does, not what it doesn't do. If safe- Part 2 continued from page 26 ty and outcomes are controversial, which I think is reasonable, what I focus on is predictability, accuracy, reproducibility. If I can automate the steps of the procedure, I think that's better for my patient, and that's why I do it. Dr. Zaldivar: We were skeptical at the beginning so we used it a couple of times. We weren't convinced and we didn't adopt it as we should have 100%. The technology has evolved and now it's much more predictable, it's faster, it's better, and now we are ready and we are happy with how we are using it, which is in around 20% of our patients. I think it's going to grow a lot. Dr. Waring: I'm going to summarize the point about how we priori- tize the benefits and the uniform capsular overlap over the optic. It is well published in the peer-reviewed literature that tilt and decentration can matter and if you can minimize that variable alone, that's big. Do you need a femtosecond laser to do it? No, we have other technologies, however, the whole package is so compelling, we think it makes sense to provide this to as many of our patients who are willing to have it, and that's almost all of them. We think it makes a difference because we're addressing everyone's focus, to get back to our outcome-driven ideology. Dr. Dell: I think that each of us should be selecting the pieces of technology that we think will allow us to deliver the result that we want for our patients. It's rare that this remains static. It constantly evolves, and we're all striving to search for those best technologies, and we will continue to do that. Dr. Clinch: As the first laser cataract surgeon in our area, I have always counseled patients that standard cataract surgery is a good procedure. You can achieve a phenomenal outcome without a laser. What I try to explain to my patients is that no matter what they choose, they should do well. While my conver- sion rate is approximately 80%, it could actually be higher. I counsel specific patients who desire laser surgery that a laser is not neces- sary for their case. I think we do a disservice when we make everyone feel compelled to use any type of technology. Dr. Nehls: I think the precision is amazing. It's relatively new technol- ogy. It's certainly going to undergo new developments, incorporation into the OR, better speed, easier docking, all of that will come down the road, and I think it's going to be a technology that will be how we do cataract surgery for most of our patients in the future. Dr. Thompson: I approach cataract surgery as a refractive surgeon, and we're identifying cataracts at young- er ages, so the lens softening aspect, in my patient population, isn't as powerful anymore. I like having access to femto in my practice, but I think as surgeons we should go into all of our surgeries with what brings us the most confidence for that sit- uation. I'm glad we have all of these technology options. Dr. Vukich: I'd like to thank all the members of this panel. It has been an excellent roundtable on what I think is an important topic and that is how do we integrate technology into our practice, the continuous reassessment of how the technology adds value, and how we continue to look for the best way to treat our patients. EW References 1. Chang DH, Waring GO. The subject-fixated coaxially sighted corneal light reflex: a clinical marker for centration of refractive treat- ments and devices. Am J Ophthalmol. 2014; 158:863–74. 2. Thompson V. Streamlined method for anchoring cataract surgery and intraocular lens centration on the patient's visual axis. J Cataract Refract Surg. 2018;44:528–533. Editors' note: Dr. Clinch has financial interests with Johnson & Johnson Vi- sion (Santa Ana, California). Dr. Dell has financial interests with Bausch + Lomb (Bridgewater, New Jersey) and Johnson & Johnson Vision. Dr. Thompson has financial interests with Alcon (Fort Worth, Texas), Johnson & Johnson Vision, and Mynosys Cellu- lar Devices (Fremont, California). Dr. Williamson has financial interests with Alcon, Bausch + Lomb, and Johnson & Johnson Vision. Dr. Nehls, Dr. Vukich, Dr. Waring, and Dr. Zaldivar have no financial interests related to their comments. Contact information Clinch: tclinch@edow.com Dell: steven@dellmd.com Nehls: nehls@wisc.edu Thompson: vance.thompson@vancethompsonvision.com Vukich: javukich@gmail.com Waring: gwaring@waringvision.com Williamson: blakewilliamson@weceye.com Zaldivar: zaldivarroger@gmail.com February 2019

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