EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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104 EW FEATURE February 2011 Cataract/IOLs, femtosecond cataract March 2013 Update on the femtosecond laser for cataract surgery by Michelle Dalton EyeWorld Contributing Writer F With more surgeons using the devices, quantifying the benefits may become easier AT A GLANCE • Femtosecond lasers for cataract surgery have made "impossible" surgeries possible. • Not all patients make good candidates for femtosecond laser surgery. • While early results indicate the lasers can improve visual outcomes, long-term data is not yet available to substantiate claims of improved safety (i.e., reduced endophthalmitis). emtosecond laser technology is a relatively new entity, first introduced for corneal surgery, then expanding its capabilities to include lamellar and penetrating keratoplasty, and now to capsulotomy and phacofragmentation in cataract surgery. Zoltan Z. Nagy, M.D., clinical professor of ophthalmology, Semmelweis University, Budapest, Hungary, believes that eventually most surgeons will be using a femtosecond laser in cataract surgery— much like how most LASIK flaps are created with a femto today. Uncomplicated cataract surgery, where no other comorbidities exist, is already an incredibly safe surgery, "so it's hard to imagine being much safer," said William W. Culbertson, M.D., professor of ophthalmology, Bascom Palmer Eye Institute, Miami, but when surgeons start discussing the femto for cataract, "we're talking about having fewer complications and getting better outcomes in terms of vision while minimizing the damage to the cornea." Reducing the number of maneuvers a surgeon must do lessens the amount of phaco energy required to the point where "we're getting close to using no phaco energy at all," Dr. Culbertson said, citing published work from H. Burkhard Dick, M.D., and others.1 The technology is still in infancy, and while pricing, surgical time, necessary skills, and learning curves can all be debated, "the technology works, and a lot more development should be expected in this field in the near future," Prof. Nagy said. Safer than manual procedures? Femto for cataract "has the potential to increase the safety of cataract surgery because the precise corneal incisions, the perfect capsulotomy, and the lens fragmentation reduce the risk of an errant capsulorhexis, the amount of phaco energy required to emulsify the lens, the amount of irrigation fluid running through the eye, intraocular manipulations, and the risk of a leaky wound," said Neil J. Friedman, M.D., adjunct clinical associate professor, Stanford University School of Medicine, and director of cataract and lens implant surgery, Pacific Vision Institute, San Francisco. (See the list of additional suggested references for more details.) No matter how good a surgeon someone is, "it's very difficult to make a perfect circle. It's very difficult to make the exact same size incision every single time," said Michael J. Endl, M.D., partner, Fichte Endl & Elmer Eyecare, Niagara Falls, N.Y. Creating a corneal incision, capsulotomy, and fragmenting the crystalline lens can all be performed continued on page 106 Table 1. Key system figures for the femtosecond lasers for cataract refractive surgery. Adapted and updated from Jonathan Talamo, M.D. OptiMedica Alcon LensAR Technolas/B+L Interface design Liquid optics (immersion lens) Curved lens Robocone (immersion lens) Curved lens Imaging type 3D spectral domain OCT 3D OCT 3D-CSI (confocal structured illumination) Online OCT Ocular surface identification Automatic or user-adjustable Manual Automatic Manual Integrated chair Yes No No Yes System dimensions (w/o bed) 35 x 65" 48 x 62" 78 x 36" (extended) 41 x 81" System origin Laser cataract surgery Femtosecond LASIK (IntraLase) Presbyopia treatment Femtosecond LASIK FDA approvals 510(k) approval for creating single-plane/multi-plane arc cuts/incisions in the cornea during cataract surgery. Previously approved for capsulotomy and/or lens fragmentation. (Sept. 2012) 510(k) approval for use in cataract surgery for anterior capsulotomy, phacofragmentation, and the creation of singleplane and multi-plane arc cuts/incisions in the cornea. (2009) 510(k) approval for use in anterior capsulotomy, with and without laser phacofragmentation during cataract surgery. (June 2012) 510(k) approval for the creation of a corneal flap in patients undergoing LASIK or other treatment requiring initial lamellar resection of the cornea; anterior capsulotomy during cataract surgery. (August 2012) European approvals CE mark for creating singleplane/multi-plane arc cuts/ incisions in the cornea during cataract surgery; capsulotomy; and/or lens fragmentation. (March 2012) CE mark for anterior capsulotomy, corneal incisions, and laser photofragmentation. (Jan. 2011) CE mark for use in anterior capsulotomy with and without laser phacofragmentation. (September 2012) CE mark for LASIK flap, astigmatic keratotomy, INTRACOR, capsulotomy, and lens fragmentation. (December 2011)