Eyeworld

EW FEATURE 120 New technology in cataract surgery • April 2016 AT A GLANCE • While some recent studies cite advantages to FLACS, others have found outcomes are not significantly different compared to manual cataract surgery. • Physicians bringing femto into practice should consider patient counseling, additional costs, and operating time. • Educators are open to training residents on femto but urge a "cautiously optimistic" approach to it. by Liz Hillman EyeWorld Staff Writer Dr. McLeod said conventional phaco surgery still outperforms fem- to when it comes to cost, efficiency, overall energy delivery to the eye, greater capsulorhexis integrity, and easier cortical cleanup. Conven- tional methods are also preferred in patients with small pupils. Dr. McLeod further explained his stance on the energy delivery of the 2 methods. "The now established con- ventional wisdom is that with the femtosecond laser, you are able to reduce energy delivery to the eye," he said. "However, that is specific to the reduced phaco energy. The total energy delivered to the eye actually comprises both femtosecond laser energy and phaco energy. We have to account for additional femtosec- ond energy that has been delivered to the eye for the capsulorhexis that The "big picture opportunities for improvement" in FLACS, Dr. McLeod added, include cost, speed, and efficiency, but he noted what he thinks are some clear benefits of using the laser at least for some specific parts of the procedure. In terms of reproducibility and predictability of the size and centration of the capsulorhexis, the femtosecond laser seems to win out over manual capsulorhexis creation, he said, adding that he has been "extremely impressed" with the cap- sulorhexis edge in the months fol- lowing surgery, preventing uneven capsular contraction. It's the laser's consistency of the edge of the capsu- lorhexis that could pose a problem though. Dr. McLeod explained its potential to skip areas and create tags, saying this "intrinsic postage stamp quality" could increase the risk for anterior capsule tear. 2015 in the Journal of Cataract & Refractive Surgery found that both FLACS and traditional cataract sur- gery were safe and had low intraop- erative complications that could af- fect refractive outcomes and patient satisfaction. 1 A 6-month follow-up study comparing the outcomes of FLACS and manual phaco surgery by Yu et al. published in December 2015 in Clinical & Experimental Oph- thalmology found similar safety and efficacy between both procedures. 2 A separate 6-month follow-up study published in July 2015 in the Journal of Cataract & Refractive Sur- gery compared visual recovery and refractive stability between the 2 procedures and found that FLACS re- sulted in faster visual recoveries and more stable refractive results, com- pared to manual cataract surgery. 3 As for visual acuity, a literature review published in Current Opinion in Ophthalmology in January 2014 found that "most but not all exist- ing studies showed no statistically significant difference in visual acuity and mean absolute refractive error between laser and conventional cataract surgery cases." 4 There was also a 2013 review published in Eye, the journal of the Royal College of Ophthalmologists, that cited several studies that con- cluded femtosecond laser use was significantly more accurate in terms of creating a reproducible capsulot- omy compared to manual capsulor- hexes. 5 Stephen McLeod, MD, chair, Department of Ophthalmology, UCSF, pointed out that the current FDA-approved femtosecond laser platforms for use in cataract sur- gery are still in their first iteration, however sophisticated they might be. Given that femto can at least compete with the high standards of manual modern phacoemulsifica- tion is impressive, he said, but the technology is still in its infancy. "It does say a great deal, howev- er, that a radically different ap- proach to some of the key elements of a procedure where the current standard has evolved over decades of refinement and sequential im- provements in instrumentation and techniques can compete at such an early stage," Dr. McLeod said. With FLACS still in its infancy, physicians discuss the research, bringing it to practice, and education T he femtosecond laser is not the first and it's certainly not the last of new tech- nologies that could revolu- tionize the way physicians perform cataract surgery. But the jury is still out on whether the tech- nology—approved by the U.S. Food and Drug Administration for this purpose in 2010—trumps traditional cataract surgery technique. Within the last decade, hun- dreds of studies involving femtosec- ond laser-assisted cataract surgery (FLACS) have been published, with more to come. So what does the cur- rent research have to say? How are physicians currently bringing it into their practice? And how is it being introduced to residents? "I think ophthalmology in general is still trying to grapple with … how we optimize the usefulness of the femtosecond laser in our practices," said Saras Ramanathan, MD, associate professor of ophthal- mology, University of California, San Francisco (UCSF) School of Medicine. "Ophthalmologists in this country are still trying to figure out how the femtosecond laser fits into their practices—we don't all agree." All eyes on the data A study of 4,000 cases from a single center in Tasmania published in Femto in cataract surgery: The state of the technology Dr. Ramanathan teaches resident Chris Aderman how to use the femtosecond laser to create corneal incisions and capsulorhexis in a patient at UCSF Medical Center. Source: UCSF continued on page 122

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