Eyeworld

SUMMER 2024 | EYEWORLD | 33 C by Liz Hillman Editorial Co-Director About the physicians Kendall Donaldson, MD Medical Director Bascom Palmer Eye Institute, Plantation Plantation, Florida Jonathan Rubenstein, MD Chairman and Deutsch Family Endowed Professor Department of Ophthalmology Rush University Medical Center Chicago, Illinois References 1. Yong WWD, et al. Comparing outcomes of phacoemulsi- fication with femtosecond laser-assisted cataract surgery in patients with Fuchs endothelial dystrophy. Am J Ophthalmol. 2018;196:173–180. 2. Teshigawara T, et al. The advantages of femtosecond laser-assisted cataract surgery for zonulopathy. Int Med Case Rep J. 2019;12:109–116. 3. Assaf AH, et al. Femtosecond laser-assisted cataract surgery in soft and hard nuclear cata- racts: a comparison of effective phacoemulsification time. Clin Ophthalmol. 2021;15:1095–1110. I n the decade-plus since its approval, fem- tosecond laser-assisted cataract surgery (FLACS) has essentially divided cataract surgeons into two camps: loyal proponents and frequent users of the technology and those who do not think that it brings value to their practice. Many studies in peer-reviewed literature do not find that FLACS significantly improves outcomes or safety compared to conventional cataract surgery methods (with some exceptions for comorbid conditions). But EyeWorld spoke with two surgeons who say they consistently benefit from FLACS in their practice. "I'm very bullish toward [FLACS], and I use it now more than I ever have," said Jonathan Rubenstein, MD. Dr. Rubenstein started to engage FLACS in 2017. The FDA approved the use of the femto- second laser for several functions in 2010—cor- neal incisions, anterior capsulotomy creation, photofragmentation, and limbal relaxing inci- sions. In the early years after its approval, there was a lot of buzz about the new technology, but as physicians over time determined how it does (or doesn't) fit within their practice, some of the chatter at medical conferences, for example, has waned. Dr. Rubenstein said this loss of the initial enthusiasm is normal but this has not dimin- ished his belief in the benefits of the technology for his patients. Initially, when something is new, it has a lot of sparkle. That novelty plus the added allure of using a laser technology earned FLACS a lot of attention. Secondly, and most impactful for adoption vs. non-adoption was the expense of the laser and the ability to access the machine. "There are people who do not own or have ready access to the laser who do not think it is tremendously improving their outcomes or adding to their ability to grow their practice," Dr. Rubenstein said, adding that he can see how high-volume cataract surgeons especially might have a harder time working FLACS into their surgical flow. Dr. Rubenstein said he has a lower volume practice, performing about 10 cataract proce- dures on an OR day. He finds FLACS fits well into his practice. "For me, it is not a significant time factor. It's a value added," he said, explaining that in the majority of his cases (75%), he uses the femtosecond laser. "I think I perform better cat- aract surgery with the femtosecond laser tech- nique. I think I do very good surgery without it, but I think I offer a slightly better product for the patient with FLACS." One reason surgeons and studies might not see some of the added benefit with FLACS in their typical cataract cases, Dr. Rubenstein thinks, is because they might still be using the same surgical technique. "I think what a lot of surgeons still do not realize is that surgical technique when doing femtosecond laser-assisted cataract surgery is significantly different than regular cataract surgery. If you go in with your same phaco technique after you have lasered the cataract, it doesn't significantly change anything," he said. "But if you utilize the laser effectively to break up the nucleus of the lens in a specific way and tailor your lens removal technique to correspond to the laser pattern, I think it's much more efficient." Kendall Donaldson, MD, said that discus- sion regarding femtosecond laser use in cataract surgery was popular when the technology was new, as is true for many new technologies. "At this point, most surgeons have chosen sides and have settled into a stable practice pattern," said Dr. Donaldson, who first began using FLACS in 2011. "We have to consider cost commitments, as well. A femtosecond laser is a significant financial commitment for a practice, and this investment needs to be considered in each practice setting." Peer-reviewed studies and case reports sup- port FLACS as advantageous over conventional cataract surgery in some cases with comorbid conditions. 1–3 "As a cornea specialist, I think [FLACS] has special value. I use it a lot in Fuchs dystrophy patients and any patients who have corneal endothelial compromise, and that is one place where the literature does support its use. … It's been shown that these patients have less Perspectives supporting femto in modern cataract surgery continued on page 34

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