Eyeworld

Live: 9.5"x12.5" Carling Communications Issue Date: 7/2014 T EW NEWS & OPINION 14 Dr. Chang: Describe your profes- sional background and practice. Prior to your literature review, what was your experience with and interest in the femtosecond laser cataract procedure? Dr. Lipstock: I am a graduate of the Medical College of Virginia where I also did my residency. I immedi- ately entered private practice in Richmond in 1987. As a general ophthalmologist I soon developed an interest in refractive surgery. When IntraLase made its first show- ing at ASCRS years ago, I spoke with Eric Weinberg, their marketing/ business director. The first question I asked Eric was how effective was it for LASIK, and the second question I asked was have you thought about using it for cataract surgery. To the latter he responded that they had been working on that aspect for some time. That was well over a decade ago. When these same folks unveiled it at ASCRS a few years ago it definitely caught my attention. Less corneal and macular edema? Safer capsulorhexis? More accurate placement of the IOL? Who wouldn't consider it despite the hefty price tag? But it was moot since there seemed to be little interest in purchasing one at our ASC, and no competitors in the area had purchased one either. Dr. Chang: What prompted you to research the FS laser cataract procedure? Dr. Lipstock: While in London at my son's graduation last July, I arranged to spend some time observing Julian Stevens, FRCS, performing laser vision correction. While there Dr. Stevens was very ex- cited about his Catalys femtosecond laser (OptiMedica/Abbott Medical Optics, Santa Ana, Calif.). Immedi- ately upon returning home I called my Alcon rep as well as the Catalys rep. I soon traveled to watch two experienced surgeons do about 15 cases each with their lasers. I saw two incomplete capsulotomies with the LenSx (Alcon, Fort Worth, Texas), with the updated SoftFit PI, and one anterior radial capsular tear with the Catalys. Talk about catching my attention! At the same time I was planning on giving a talk to a group of local optometrists. It was going to be on IFIS, but after this I changed the topic to femtosecond laser-assisted cataract surgery (FLACS). Dr. Chang: How did you go about researching the FS laser procedure, and how long did this take? Dr. Lipstock: I first started reviewing abstracts from PubMed searches. Early on I looked at some review articles but mostly I tried to look at the FLACS literature beginning in chronological order. I organized the printed articles with my accompany- ing summary outlines into different folders (e.g., capsulorhexis smooth- ness and strength, IOL tilt and decentration, corneal edema, etc.). I soon noticed certain patterns emerging. First it appeared early on that the vast majority of articles in the peer-reviewed journals had authors with financial ties. Not only that, but most of the studies were being done by the same few research teams from the different laser com- panies. As I read through them I went into more depth by following the references in each article. I learned about the effect of decentra- tion and tilt on negative aspheric versus neutral and spherical IOLs and how that related to claims being made that FLACS capsulotomies were better. I learned about the studies of Dr. Apple and others about the smoothness and strength of Neuhann's and Gimbel's manual capsulorhexis. I started reviewing the literature in August and by the time December rolled around I found myself getting further involved to the point that I was July 2014 by David F. Chang, MD What our patients would want C linicians must continually evaluate new technologies by relying on varied sources of information. Besides company sales literature and reps, and the opinions of trusted colleagues who have used or studied the technologies, we ultimately place great value on peer- reviewed studies. Because of how it is being marketed to surgeons (by industry) and to the public (by some practices), one of the most controversial and polarizing technologies has certainly been the femtosecond (FS) laser for cataract surgery. For this reason, I was very impressed by the extraordinary efforts of Ken Lipstock, MD, a general ophthalmologist in private practice, to independently study the evidence establishing the clinical benefits of the FS laser. Ken and I had previously cor- responded about his efforts to educate local prescribing MDs about IFIS, and he recently emailed me a PowerPoint summary of his comprehensive review of the literature on FS laser cataract surgery. He has also posted this on the ASCRS Cataract List Serve. Like many of us, Ken was interested in whether or not to offer this technology to his own refractive cataract patients. Since 1987, Ken has been in solo private practice in Richmond, Va., and the ASC in which he both practices and owns shares does not have a FS laser. Reviewing the many studies on this technology is no easy endeavor, and I marveled at the thoroughness and objectivity with which he independently undertook this project. All ophthalmologists have the capability to do this, but I am not sure that anyone else has. The PowerPoint executive summary that Ken developed is a tremen- dous resource for anyone seeking to understand the published evidence, and he has made this available to interested ophthalmologists at femtocataractppt.com. Because of the favorable cachet that patients attach to "laser" cataract surgery, it is easy for surgeons in competitive markets to be influenced by fear. Our patients, however, trust us to employ our medical and scientific training to ethically and objectively decide what is best for them. I applaud Ken for striving to do just that and for being willing to share his exhaustive research effort with the rest of us. David F. Chang, MD, chief medical editor Ken Lipstock, MD continued on page 16 Chief medical editor's corner of the world 12-29 News_EW July 2014-DL_Layout 1 6/30/14 8:38 AM Page 14

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