Eyeworld

EW FEATURE 122 New technology in cataract surgery • April 2016 advancing technology and options for our patients, it serves us well to responsibly apply this new platform and help to move it forward." EW References 1. Abell RG, et al. Femtosecond laser-assisted cataract surgery versus standard phacoemul- sification cataract surgery: outcomes and safety in more than 4,000 cases at a single center. J Cataract Refract Surg. 2015;41:47– 52. 2. Yu Y, et al. Comparative outcomes of femtosecond laser-assisted cataract surgery and manual phacoemulsification: a six-month follow-up. Clin Experiment Ophthalmol. 2015 Dec 30. 3. Conrad-Hengerer I, et al. Comparison of visual recovery and refractive stability between femtosecond laser-assisted cataract surgery and standard phacoemulsification: six-month follow-up. J Cataract Refract Surg. 2015;41:1356–64. 4. Chen H, et al. Visual and refractive out- comes of laser cataract surgery. Curr Opin Ophthalmol. 2014;25:49–53. 5. Trikha S, et al. The journey to femtosecond laser-assisted cataract surgery: new begin- nings or a false dawn? Eye. 2013;27:461–73. 6. Donaldson KE, et al. Femtosecond laser-as- sisted cataract surgery. J Cataract Refract Surg. 2013;39:1754–63. Editors' note: The physicians have no financial interests related to their comments. Contact information Chiu: Cynthia.Chiu@ucsf.edu McLeod: Stephen.McLeod@ucsf.edu Ramanathan: saras.ramanathan@gmail.com Srikumaran: dsrikum1@jhmi.edu A possible negative to FLACS at the practice level could include longer operating times. Dr. Chiu said it only adds about 5 minutes to her manual phaco time at a dedicated ophthalmic ambulatory surgery center. At UCSF, where there are more regulations for the university operating room compared to private practice, Dr. Chiu said the femto laser has added about 20 minutes to operating times. The cost of the femtosecond laser to achieve refractive outcomes, such as astigmatism correction at the time of cataract surgery, is not covered by Medicare or private insurance. Thus, patients must be counseled and consent to paying for this additional charge out of pocket. Resident programs and FLACS If established physicians are still figuring out how FLACS may or may not fit into their practice, what then is the responsibility of educators training the next generation of ophthalmologists? Dr. Ramanathan admitted she is still deciding how she feels about FLACS compared to traditional methods based on outcome data but thinks there is a responsibility to teach the new technology nonetheless. "I don't know exactly how much femtosecond laser cataract surgery I'm going to be doing 5 years from now, but I suspect that this is the direction our field is moving; just as a lot of people were late to the phacoemulsification party and regretted it, I think we can't be late to the femto party," she said. "We have to see where this tech- nology is going. … There are going to be numerous iterations to what we're doing, but I'd rather become comfortable with the technology now and let my residents become comfortable with it, so that the learning curve for them is not so steep later." As for when to start FLACS education for residents, Dr. Ramanathan said they need to be comfortable with phaco first, otherwise they would not be able to handle complications that could occur with femto. Furthermore, some aspects of femtosecond surgery could make the later phaco portion more difficult, such as in cortical cleanup. Overall, Dr. Ramanathan en- courages her residents to be "cau- tiously enthusiastic" with femto and with other new technologies that will come down the pike. "I advise my residents to always use the tools of evidence-based med- icine that we all learn throughout medical school," she said. "Having said that, always keep an open mind because when things are new, some- times we don't know what role they will eventually play in our practices. We always have to walk a line of being not too ready to adopt some- thing just because it's new, but not too late to adopt something when it's been shown to be beneficial." Divya Srikumaran, MD, assis- tant professor of ophthalmology, Wilmer Eye Institute, Johns Hop- kins University, Baltimore, said that while residents should be aware of the newest technologies, they need to have "a very healthy sense of the appropriateness" of them. "Sometimes it's easy to get carried away with what is perceived as the latest and greatest," she said. "You should have a healthy amount of skepticism as to whether it's really better and challenge all your train- ees to make sure they are exploring that with every new technology before they incorporate it into their practice; we have to model that with our behavior as well as in our teach- ing practices." So where are we now? "Standard phaco and femtosec- ond cataract surgery have evolved to the point that if done well in experi- enced hands, both will have excel- lent outcomes," Dr. McLeod said. "However, femtosecond cataract sur- gery is in its infancy, so its trajectory likely far outpaces that of phaco, and so in the interest of collectively in standard phaco is achieved me- chanically, as well as the femtosec- ond energy that has been delivered for the lens cleavage." As for the laser making frag- mentation easier, Dr. McLeod said that is a benefit, especially for surgeons who are less comfortable with energy-reducing phaco chop- ping techniques. "This can also enhance patient safety in cases of loose zonules because the lens is disassembled with less effort, which can reduce zonular stress and risk of zonular dehiscence," he said. Bringing femto to practice Once physicians decide to bring the femtosecond laser into their practices for cataract surgery, they have to prepare to talk about it with patients. As the ASCRS Refractive Cataract Surgery Subcommittee said in a 2013 article, providers have a "tremendous responsibility" in informing patients of their options as femto vs. manual "brings with it technical, ethical, and financial challenges." 6 "We are only beginning to com- prehend the benefits and complex- ities of this exciting new technolo- gy," the subcommittee wrote. In addition to physicians intro- ducing patients to FLACS, some- times it is the patient who brings up the option. "Some patients have researched the femtosecond laser and request this by name during cataract eval- uation," said Cynthia Chiu, MD, associate professor, UCSF, adding that she only offers it in combi- nation with premium intraocular lens use or for corneal astigmatism correction. "Due to direct imaging of the cornea, the femtosecond laser can create intrastromal AK incisions with precision in the depth of treat- ment. Studies are starting to report the improvement in uncorrected visual acuity using femtosecond lasers due to the reduction of the corneal cylinder. Even patients re- ceiving monofocal IOLs can benefit from astigmatism correction because many surgeons do not offer toric IOLs below a cylinder of 1.5 D," she said. Dr. Chiu said she has always been comfortable discussing pre- mium cataract services with her patients, even prior to femtosecond laser options. "It has become a more com- mon discussion now that lower amounts of corneal astigmatism can be well-treated at the time of the surgery," she said. Femto continued from page 120 " I advise my residents to always use the tools of evidence-based medicine that we all learn throughout medical school. Having said that, always keep an open mind because when things are new, sometimes we don't know what role they will eventually play in our practices. " –Saras Ramanathan, MD

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