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EW CATARACT 24 July 2015 Device focus by Michelle Dalton EyeWorld Contributing Writer Steady improvements in features over the past few years have helped acceptance, but the technology is still not a "must-have." Here's why T oday's femtosecond lasers for cataract surgery are capable of doing limbal relaxing incisions, clear corneal incisions, anterior capsulotomy, and lens fragmenta- tion, promising physicians a more precise surgery overall. But like any other technology, it's not yet perfect. For one, femtosecond lasers are not really integrated into the overall cataract suites, said Daniel A. Black, FRANZCO, senior lecturer at the University of Queensland, Australia. The lack of seamless integration is one major reason why the majority of Australian physicians have yet to embrace the technology, he said. Over the past 2 years, "we've seen a ton of improvement" in the technology, said Mitchell P. Weikert, MD, associate professor and residency program director, Cul- len Eye Institute, Baylor College of Medicine, Houston, and medical di- rector, Lions Eye Bank of Texas. Even so, economics are going to remain a factor for most practices, he said. Joseph P. Gira, MD, Ophthal- mology Consultants, St. Louis, disagrees that pricing is the out- standing hurdle to acceptance and that it's more of a physician comfort level. "Selling the femto is easier than selling a premium IOL," he said, be- cause the term "laser" implies more precision in patients' minds. Dr. Black said in Australia, physicians are also concerned about efficiency—and the laser adds about 30% more time to an average cata- ract surgery. "So it adds more time, it's not integrated, and it's not cost-efficient. It doesn't provide a superior visual outcome or a faster visual outcome, and some early papers suggest- ed there might be slightly higher complication rates," Dr. Black said. "But once it's truly integrated into existing cataract suites, then I think it will take off." Patients are familiar with the concept of assisted surgery. In the early days of phaco, dedicated technicians were necessary. "Now they're all integrated and it's much easier," he said. Great benefits Dr. Weikert said the feature of the Catalys laser (Abbott Medical Optics, Abbott Park, Ill.) that he prefers the most is that it "fragments the lens very nicely," and that reduces phaco time. He hopes incremental improvements in fragmentation capabilities will continue so patients with dense lenses and Fuchs' dys- trophy will continue to have their surgical risk reduced. Dr. Gira uses 3 of the 4 systems (Victus, Bausch + Lomb, Bridgewa- ter, N.J.; LenSx, Alcon, Fort Worth, Texas; and the Catalys). While they are all superior devices, they do have nuanced differences, he said. "The software on the Catalys is a lot more user-friendly, so it's easier to verify the treatment and it makes changes on the fly," he said. With the Victus, a recent upgrade incor- porated auto-recognition, and it al- ready incorporated one of the fastest optical coherence tomographers on the market, he said. "It's the only one that produc- es live OCT imaging while you're doing the procedures," he said. "You can see the flume, the gas bubbles going up from the lens, or the aque- ous going in a vortex pattern from the cut." The Catalys and the Victus have a fixed bed, which "isn't as big a deal as we thought it might be," Dr. Gira said, noting some stretchers may not be stiff enough for the patient, who could inadvertently move. "We'll of- ten remove the headrest to put one that's a bit stiffer underneath, just so there's not as much movement backward." Incorporating femto into the practice There's still some debate about the best location for the laser itself— when it's outside the OR there is more inherent flexibility for multi- ple surgeons to use it on the same day. "But if you want to do some more esoteric procedures, for exam- ple, if you want to put in a pupil expansion device and then perform the laser treatment, we can't do that because it's not in the OR. If we want to do a posterior capsulotomy after we've taken the cataract out, we can't do that because we're not in the OR," Dr. Weikert said. The amount of additional time added onto the procedure is plat- form-dependent, but Dr. Weikert said each one might add 5 to 10 minutes to each patient. The Catalys incorporates a bed, so the patient has to be transferred back and forth from the stretcher to the device; the LenSx does not include a bed, so the patient does not need to be trans- ferred. Tweaking still needed Nothing is perfect, and the femto- second laser for cataract surgery is no exception. Yet most agree the current iterations are pretty close; likewise they also agree it's a case of cost and not the technology itself that is impeding rapid acceptance in the marketplace. In Queensland, Dr. Black said there's only one femto (and about 100 ophthalmologists), and that one practice "probably only uses it on 20% of their cases." Other areas have implemented the technology a bit more rapidly, but penetration rates are still in the mid-single digits. "In Australia, it's being used as more of a marketing tool," Dr. Black said. But being able to "do more" may not be necessary, Dr. Gira said. Both the LenSx and the Victus can make flaps, but it's an expensive upgrade and most surgeons don't perform LASIK in the same ASC as they do cataract surgery. "When digital cameras first came on the market, a lot of them Improving femto for cataract Are you a fan of EyeWorld? Like us on Facebook at: facebook.com/ EyeWorldMagazine Find us on social media EyeWorld@EWNews Keep up on the latest in ophthalmology! Follow EyeWorld on Twitter at twitter.com/EWNews " The manufacturers are looking at different ways to speed [the softening of the nucleus] and make it more efficient by using less energy. In the next few months, we're going to see this technology get better, faster, and less expensive. " –Joseph P. Gira, MD

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