Eyeworld

EW NEWS & OPINION 16 Considering new possibilities for femtosecond technology F rom lenticule extraction to etching flaps with the fem- tosecond laser and more, this technology is making inroads in many areas of ophthalmology, according to Ginny L. Kullman, M.D., assistant profes- sor, Ochsner Medical Center, New Orleans. In the September-Novem- ber 2010 issue of Seminars in Oph- thalmology, Dr. Kullman, together with Roberto Pineda, M.D., assis- tant professor of ophthalmology, Harvard Medical School, Boston, and director of refractive surgery, Massachusetts Eye and Ear Infir- mary, Boston, reviewed the latest ad- vances in this area. "I was doing my fellowship at Massachusetts Eye and Ear and we had a research core review project —the topic was technological advances in the field of ophthalmol- ogy," Dr. Kullman said. "I wanted to target it more to cornea as I was doing a cornea fellowship." Dr. Kullman felt that there was a lot of burgeoning interest in the femtosec- ond laser, which she was intrigued by, and she had just done a fem- tosecond corneal tattooing proce- dure with Dr. Pineda—something that she saw as a novel technique. Spurred by this, she decided to re- view the latest alternative applica- tions for the femtosecond laser. Traditionally, the femtosecond laser has been used in the refractive arena. "It was originally approved for refractive surgery and cutting LASIK flaps," Dr. Kullman said. "It had a secondary indication for the implantation of the intracorneal rings." Interest has since expanded into indications running the gamut from cataract to retina. Broadening applications Dr. Kullman found that use of the femtosecond laser for cataract sur- gery was one of the leading areas of interest. "There are a lot of femtosec- ond lasers under study for the differ- ent stages of cataract surgery," she said. The femtosecond technology can help in a number of ways. "We can use the femtosecond laser for anterior capsulotomy, lens fragmen- tation, the main cataract incision, and if there's any astigmatism, that can be addressed as well," Dr. Kullman said. "The idea is that we can specifically determine the size, shape, and diameter of the capsu- lorhexis, which is important for cen- tering the accommodating and premium IOLs for the refractive out- come of those lenses." The hope is that the femtosecond laser will im- prove visual outcomes for those patients desiring premium or accommodating lenses. In the refractive surgery do- main, Dr. Kullman found that there are a lot of novel techniques that are being investigated. "One is the FLEx [femtosecond lenticular extraction] procedure, which is refractive laser surgery, but it obviates the need for the excimer laser," she said. "It's all done with the femtosecond laser, and we produce an intrastromal lenticule that's extracted either with the hinge, which is the FLEx proce- dure, or without the hinge through a small incision, which is called small-incision lenticule extraction, or SMILE." These two techniques are basically the same with a slight vari- ation in the incision used to remove the lenticule. "You don't have the full side cut for the SMILE incision," Dr. Kullman said. "For those patients it's the bladeless laser." Work in the initial FLEx trials was targeted at those with very low myopia. "It didn't have an exact nomogram designed, but I think the more patients that they experiment on, the more reproducible results can be," Dr. Kullman said. In addition, investigators con- sidered an intrastromal technique to correct presbyopia, which involved using the laser to deliver some in- trastromal circumferential cuts. "This is interesting because we're not creating a flap, and there's no tissue being removed," Dr. Kullman said. "By shifting the biomechanics of the cornea, the idea is that we can improve near vision." The group targeted for study here were emmetropic patients of presbyopic age. Results with the technique showed that patients' near vision improved, but there was a downside. "Unfortunately, for some of the patients, their distance vision dropped a few lines, so it's a tradeoff," Dr. Kullman said. "But there's no pain and no risk of infec- tion." Future possibilities Dr. Kullman thinks that one of the newer applications is going to be im- plementing the femtosecond laser for lamellar keratoplasty surgeries. "Anterior lamellar keratoplasty is pretty straightforward because we're not going very deep and just remov- ing the top 100 or 200 microns of cornea," she said. "Posterior lamellar surgery is still relatively novel as far as how deep we can go with the laser, but I think that they're trying to prepare tissue for DSEK surgeries now with the femtosecond laser." On the downside, there are concerns about endothelial cell loss, and there can be a learning curve. Even so, Dr. Kullman is optimistic. Another possible application of the femtosecond laser may be in conjunction with collagen crosslink- ing. "Classically when we create a corneal ablation, we remove the ep- ithelium and apply the riboflavin and the UV [ultraviolet] light," Dr. Kullman said. "We found one study looking at making a flap [with the femtosecond laser] without lifting it, injecting the riboflavin into the flap, and treating the UV flap on an in- May 2011 by Maxine Lipner Senior EyeWorld Contributing Editor Femtosecond phenomenon: Burgeoning alternative applications placed in jeopardy. The major concerns that were raised during the debate on this issue included the following: • IPAB is unnecessary. While the purpose of IPAB is to reduce the per capita rate growth of Medicare spending indefinitely, in most years, Medicare's per capital growth has been below or equal to growth in the private sector; • The IPAB reductions would be in addition to the $400-500 billion savings in provider payments al- ready included in the healthcare reform legislation, which could jeopardize both access for Medicare beneficiaries and infra- structure for the entire healthcare system; • IPAB would essentially assume au- thority over the Medicare pro- gram; • IPAB would only be accountable to the President; • The proposal usurps congressional authority over the Medicare pro- gram, therefore greatly limiting the ability of Medicare beneficiar- ies, advocates, and providers to work with Congress to improve the program. As if the provision is not bad enough as it is, recently President Obama released his Deficit Reduc- tion Proposal, which includes the recommendation from the National Commission on Fiscal Responsibility and Reform (the Debt Commission), co-chaired by former Senator Alan Simpson and Erskine Bowles, former chief of staff for President Clinton, to "strengthen" IPAB. This would be done through various tools and mechanisms including reducing Medicare's target growth by gross domestic product (GDP) per capita plus 0.5%, as well as giving IPAB the ability to automatically sequester Medicare spending. ASCRS, in conjunction with the Alliance of Specialty Medicine, im- mediately responded with a press re- lease reiterating concerns with IPAB and the President's proposal to ex- pand it (see sidebar). As previously indicated, ASCRS and the Alliance support the repeal of IPAB and have issued letters of support for the re- cently reintroduced House bill by Congressman Philip Roe, M.D. (R- TN), H.R. 452, the Medicare Deci- sions Accountability Act of 2011, and the Senate bill, S. 668, the Health Care Bureaucrats Elimination Act, introduced by Senator John Cornyn (R-TX) to re- peal the Board. ASCRS, along with the Alliance of Specialty Medicine, medical physician specialty organizations, and consumer and patient groups, will work with members of Congress in both parties to repeal IPAB or at the very least modify it. This continues to be one of our top priorities. EW The Independent continued from page 15 continued on page 18

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