Eyeworld

EW FEATURE 30 by Enette Ngoei EyeWorld Contributing Editor Femtosecond lasers take center stage W ith promises of better safety, efficacy, and consistency, the fem- tosecond laser for cataract surgery, now commercially available in the U.S., has seen an international growth in interest as well as global competition among manufacturers. Alcon (Fort Worth, Texas) is marketing the LenSx Laser in the U.S. and around the world, OptiMedica (Santa Clara, Calif.) is beginning distribution of its Catalys Precision Laser System in Europe after receiving CE mark approval, and Bausch + Lomb (Rochester, N.Y.) and Technolas (Munich, Germany) are promoting the VICTUS Femtosecond Laser Platform, an all- in-one platform for refractive and cataract applications. The technol- ogy is expected to be a major focus in 2012 in the U.S. and globally. But with the high costs involved in acquiring the laser, the uncertain cost effectiveness, and slowdown in workflow it brings, will the technol- ogy gain a wide acceptance? The ex- perts EyeWorld spoke with said yes. An unstoppable technology "There's no way to stop new tech- nology," said Günther Grabner, M.D., director, University Eye Clinic, Paracelsus Medical University, Salzburg, Austria. For one, patients like to hear the word "laser" because it sounds sexy and they love to hear that there's no knife involved, he explained. What's more is there are six companies that he knows of that have spent a total of about $2 billion in research and development of the technology. "I don't think that there's a way out because they will push forward and this will be a technique that will be implemented. I don't know if it will be 3, 5, or 10 years—my guess is that it will be about 5 years. About 40% probably will have switched to this technique," Dr. Grabner said. If the laser isn't widely adopted, it will probably be because of the high price tag associated with it, Dr. Grabner said. "There are very few centers that can make a profit after spending 450,000 euro or dollars, plus about $40-$50,000 per year maintenance fee, plus $300-$450 per case click fee," he explained. However, according to H. Burkhard Dick, M.D., chairman, University Eye Hospital, Bochum, Germany, the financial burden be- hind acquiring the laser will not be a barrier to its widespread adoption. "As a matter of fact, we had this same discussion with femto LASIK 10 years ago and now I do femto LASIK on nearly every patient. Ini- tially I thought, why should I pay 450,000 euros for a device that only makes a flap? Now everyone uses it and I would not go back to micro- keratomes," he said. A real difference? While the femtosecond laser may create more precise, well-centered, safer capsulotomies, the question re- mains whether the capsulotomy sig- nificantly affects outcomes. According to Rudy Nuijts, M.D., associate professor, Academic Hospital Maastricht, the Nether- lands, the capsulotomy is important in terms of centration of the lens, especially when surgeons are using more sophisticated premium IOLs. "Decentration and tilt of lenses is even more important because we know that with toric and multifocal lenses, if there is decentration to a certain extent, this will decrease and limit the outcome of the procedure," he explained. For the experienced surgeon, routine capsulorhexis at a certain di- ameter, configuration, and place- ment is not a big issue, but surgeons can now guarantee that to every pa- tient, Dr. Dick said. However, he said, while there is some data out, there have not been controlled, comparative, masked tri- als. "It's not data driven, but I'm convinced," he said. Logistical considerations The optimum location for the laser is yet to be determined. For Dr. Dick, it will be in the OR and not in the refractive surgery center. This is be- cause it presents a problem in terms of timing. The moment the anterior capsule is opened, some elements are released. Some production of chemicals in the eye is initiated be- cause the aqueous has access to the lens material, which could cause the pupil to constrict, he said. Dr. Grabner said the best loca- tion for the laser depends on the set- up of the clinic. "I have a clinic at the University Eye Clinic in Salzburg that has three fully-equipped ORs plus a laser room. We probably will need an ad- ditional room in front to place the laser; all the initial cuts can be done there and then the patients will be brought into the ORs," he said. Dr. Grabner also knows of smaller set-ups that have placed a laser in the OR and use one operat- ing table for both the femtosecond incision plus the remainder of the surgery. The best working model has to be worked out in practice, Dr. Nuijts said, and it's too early in his experi- ence to recommend what would be the best position in terms of strategy and workflow. Will the laser be shared among physicians? Dr. Dick said, "Absolutely. Un- less you have a volume of 3,000, it's mandatory. You have to have a large volume to make it pay." Surgeons who have a very low volume will have to share the laser with five to eight other surgeons with the same volume, he said. February 2011 What's ahead in 2012 December 2011 As the advanced technology moves into the spotlight in 2012, EyeWorld looks at some of the key issues surrounding its adoption worldwide in cataract surgery AT A GLANCE • Patients like to hear the word "laser" because it sounds sexy and they love to hear that there's no knife involved • The financial burden behind acquiring the laser will not be a barrier to its widespread adoption • The costs of the procedure cannot be addressed from one standpoint and will depend on the healthcare system wherever the practice is located • The optimum location for the laser will be in the OR and not in the refractive surgery center With the femtosecond laser, the capsulorhexis can be placed precisely where the surgeon wants Source: William W. Culbertson, M.D. continued on page 31

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