DEC 2013

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

Issue link: https://digital.eyeworld.org/i/227001

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EW International 48 December 2013 Views from Asia-Pacific: Femto for cataract surgery Cesar Ramon G. Espiritu, MD I n the March issue of EyeWorld, a feature article updated readers on femtosecond lasers for cataract surgery. The article surmised that quantifying the benefits may become easier as more surgeons start using the lasers. Zoltan Z. Nagy, MD, clinical professor of ophthalmology, Semmelweis University, Budapest, Hungary, told EyeWorld 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. Sri Ganesh, MD The technology is still in its 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. In our sister publication, EyeWorld Asia-Pacific, Cesar Ramon G. Espiritu, MD, Philippines, and Sri Ganesh, MD, India, shared their thoughts on the technology. Dr. Espiritu: In August 2011, the American Eye Center in Manila, Philippines, became the first in Asia to acquire the LenSx femtosecond laser system (Alcon, Fort Worth, Texas). Since then we have, in a short span of time, shifted our cataract cases toward 49.2% femtosecond-assisted as per 2012 figures. This has allowed us to gain region-leading experience with the technology and to reap all the benefits of the repeatable, precise, well-constructed capsulotomies and corneal incisions, as well as the marked decrease in phacoemulsification energy required to remove standard cataracts and, more importantly, challenging ones. Cases such as rock-hard cataracts, intumescent and subluxated lenses are now handled with less difficulty and with increased success. Since 39.6% of our cases choose advanced technology IOLs (ATIOLs), postoperative emmetropia is extremely important in assuring patient satisfaction. The keys to this are, first, a predictable effective lens position (ELP) and, second, a consistent surgically induced astigmatism (SIA) from our incisions. Femtosec- ond-produced capsulotomies that are programmed in size and location, that are almost identical in every case, and that ultimately ensure complete capsular bag capture have definitely contributed to achieving preoperatively predicted ELPs. Being able to produce precise corneal incisions with regard to size, architecture, and location has significantly reduced the variability of SIAs compared to manually produced ones. In addition, femtosecond laser arcuate cuts that are made at precise depths and widths have justifiably made us take a second look at this mode of astigmatism management. All that remains is to establish any undesired regression over time. With incisions, capsulotomies, and nuclear fragmentation now computer controlled, and with upgrades providing improved imaging, the logical progression of this technology into the future is to minimize, if not eliminate, positioning error through eye registration. Primary, secondary, bimanual and arcuate incisions can then be made in the desired axes and distances from the limbus. Capsulotomies can then be centered on the surgeon's choice of either the pupil center or visual axis. A feature that will aid in positioning toric IOLs without having to mark should also come in the near future. These developments will, without question, raise the bar and widen the gap between femtosecond laser-assisted cataract surgery and phacoemulsification. We should then see a rapid shift of early skeptics to convinced converts. Dr. Ganesh: As cataract and refractive surgeons, we are constantly in pursuit of ensuring that our patients attain maximum uncorrected visual acuity after our interventions. Femtosecond laser-assisted cataract surgery represents a potential paradigm shift in cataract surgery, but it is not without controversy. Femtosecond lasers presumably allow for more square architecture and stable incisions, which are more resistant to leakage, and are thought to reduce the incidence of endophthalmitis.

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