OCT 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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34 EW CATARACT October 2013 Cataract editor's corner of the world A variety of femtosecond laser options by Ellen Stodola EyeWorld Staff Writer Surgeons discuss the different femtosecond lasers for cataract surgery available "The first rule of any technology used in a business is that automation applied to an efficient operation will magnify the efficiency. The second is that automation applied to an inefficient operation will magnify the inefficiency." –Bill Gates T his quote may apply to the newest technology in cataract surgery: femtosecond lasers. While the number of cataract surgeries performed with the femtosecond laser continues to grow worldwide, the public opinion about this new technology is still mixed. A main concern about the femtosecond laser procedure is the added time per procedure and loss of efficiency. To investigate these concerns, we asked surgeons who have been using their lasers for more than a year for their candid opinions about the procedure and the pros and cons of their particular laser platforms. Bonnie An Henderson, MD, cataract editor F emtosecond laser technologies have becoming increasingly popular for use in cataract surgery. Harvey Uy, MD, Pacific Eye and Laser Institute, Makati City, Philippines; Soon-Phaik Chee, MD, Singapore National Eye Centre, and associate professor, Department of Ophthalmology, National University of Singapore; Donald Serafano, MD, associate clinical professor, Department of Ophthalmology, University of Southern California, and Complete Eye Care Associates, Los Alamitos, Calif.; and Robert Rivera, MD, director of clinical research, Hoopes Vision, Draper, Utah, commented on the specific femtosecond laser platforms they are currently using as well as the advantages and disadvantages with the various lasers. Femtosecond lasers used Dr. Uy uses the LENSAR femtosecond laser (Orlando, Fla.), which is FDA approved for all aspects of cataract surgery including corneal incisions, laser anterior capsulotomy, and laser lens fragmentation. "Together with some worldrenowned surgeons, I was fortunate to be one of the early pioneers of laser-assisted cataract surgery and performed the first femtocataract procedure in Asia on December 10, 2009," he said. The femtosecond laser procedure, Dr. Uy said, is still used mainly with premium packages. Since April 2012, Dr. Chee has been using the Victus femtosecond laser (Bausch + Lomb, Rochester, N.Y./Technolas Perfect Vision, Singapore), and she said the volume of procedures is higher for femtosecond cataract surgery. Dr. Serafano has been using the LenSx femtosecond laser (Alcon, Fort Worth, Texas) since January 2012. He said the volume of femtosecond cataract surgery is as anticipated, and the cost is definitely a factor for many patients considering this option. Dr. Rivera has experience using two different femtosecond lasers. His Dr. Serafano seated at the LenSx laser with his patient in position and the SoftFit Patient Interface docked on the right eye. Technicians assist the patient and at the laser. Source: Donald Serafano, MD center was one of the first in the U.S. to obtain the LenSx laser, and a year after that, he got the Catalys femtosecond laser (OptiMedica/ Abbott Medical Optics, Santa Ana, Calif.). He first started using femtosecond lasers in October 2011. "During the first year of our femtosecond laser experience, we were less than pleased with the way the laser could make cases more difficult, rather than easier," Dr. Rivera said. "Consequently, that first year saw only a handful of laser cataract surgeries performed each month." This has changed over time, however, mainly with the introduction of the Catalys into his center. "We've been quite pleased to see our volume of laser cataract surgeries continue to grow." Advantages and disadvantages The femtosecond laser is generally thought to make cataract surgery easier and more accurate. "The combination of laser precision and automation of several surgical steps greatly facilitates the accuracy and ease of performing a cataract procedure," Dr. Uy said. "This translates to better refractive outcomes as well as decreased phaco energy." Dr. Uy said the main disadvantage that still surrounds the femtosecond laser is the higher cost for patients undergoing the procedure. Dr. Chee said one of the advantages of the Victus femtosecond laser is the perfect capsulotomy, which she believes "contributes to the better unaided visual acuities my patients are achieving." She said the laser is also great for posterior polar cataracts, mild lens subluxations, and white and intumescent cataracts. The greatest disadvantage of the femtosecond laser in her center, Dr. Chee said, is that it is used in a different location than the operating room, so the logistics of the procedure can sometimes be challenging. Dr. Serafano said one of the main advantages with the LenSx femtosecond laser is precision. "I can look at a postoperative patient at the slit lamp and know if he/she is a femtosecond patient or a manual patient by the architecture of the primary and secondary incisions, arcuates, and centration of the circular anterior capsulotomy," he said. A main disadvantage he cited was the added cost of the procedure. Additionally, he said some patients with pseudoexfoliation or patients taking tamsulosin may not dilate well enough to perform a laser capsulorhexis or lens fragmentation. Dr. Rivera cited increased precision of incisions and the way the nucleus is fragmented and softened for removal as two of the greatest advantages of femtosecond laser technology. "This combination of effects makes the surgeries much easier on the patient, and gives us greater precision in areas we previously saw tremendous variability in, given the inability to create a manual incision in exactly the same way from case to case," he said. However, he noted that these advantages come with a cost, both in the price of obtaining the laser

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