Eyeworld

85 June 2016 EW MEETING REPORTER Editors' note: Dr. Slade has financial interests with Alcon. Dr. Bakewell has financial interests with Abbott Medical Optics. X-Rounds gives quick insights into what the experts are thinking on variety of topics As if the meeting in the Big Easy was not going fast enough, "X-Rounds: Refractive Surgery to the Max" on the last day of the ASCRS•ASOA Symposium & Congress, provided a rapid-fire, interactive symposium de- signed to give the audience diverse insights from some of the field's leading experts. Moderator Eric Donnenfeld, MD, Rockville Centre, New York, introduced the panelists—David Chang, MD, Los Altos, California; Bonnie Henderson, MD, Boston; Stephen Lane, MD, Stillwater, Min- nesota; Richard Lindstrom, MD, Minneapolis; Stephen Slade, MD, Houston; and Kerry Solomon, MD, Mount Pleasant, South Carolina—as the X-Men in the field of cataract and refractive surgery. "What makes the X-Rounds special is we incorporate a little bit of fun into our session and also a lot of education. As the audience, you get to decide the talks you like best," Dr. Donnenfeld said. manual capsulotomies, in com- parison, are smooth. And while he said there is "No question that the roundness of the femto capsulotomy is close to perfect and consistently more round than manual capsulot- omy," he found that the size of the capsulotomy is more uniform in manual cases, and the centration is "good but not always perfect." He argued that if the capsulo- tomy is the main selling point of FLACS, then the data shows the technology wanting. Dr. Bakewell did, however, con- cede that FLACS certainly decreased effective phaco time (EPT)—an important safety consideration—and that femto incisions have better structural integrity than manual incisions. Meanwhile, femto AKs, he said, are more precise than limbal relaxing incisions (LRIs), but not as predictable as toric IOLs. New technology might also be pushing FLACS aside. Initial data, he said, shows that the Zepto Precision Pulse Capsulotomy (Mynosys, Fre- mont, California) "creates a stronger capsulotomy than the femto and can be well centered over the visual axis at the cost of a disposable." Moreover, he said, "FLACS may be too cost prohibitive in some demographic areas to become the standard for cataract surgery." LASIK, Dr. Slade's patients, wheth- er fair or not, had begun to expect "LASIK-like vision" following cata- ract surgery. FLACS suggested a way to po- tentially answer the question in the affirmative. In the first 5 years of the tech- nology, Dr. Slade said that he was initially impressed and motivated by the potential for perfectly shaped, perfectly reproducible capsuloto- mies. Although at the very begin- ning a full 360-degree capsuloto- my—even a capsulotomy just over 180 degrees—was cause enough for excitement in the technology, by the end of those 5 years, completely free-floating capsulotomies were already the norm. If those first 5 years are all we've got to go on, he said that femto- second laser cataract technology is like digital technology to phaco's analog—"Imagine how far anything digital can progress in 5 years," he said. In 2016, Brock Bakewell, MD, Tucson, Arizona, remains unswayed by the technology. In his experi- ence, he said, anterior capsular tears occur at a higher incidence than with his manual technique. This is in part due to the rough "postage stamp perforations" along the edges of femto capsulotomies seen by electron microscopy—the edges of financial interests with Abbott Medical Optics, Alcon, Carl Zeiss Meditec, and other ophthalmic companies. Dr. Trindade has no financial interests related to his comments. FLACS vs. phaco In February 2010, the femtosecond laser for cataract surgery first arrived in the clinic of Stephen Slade, MD, Houston. At the time, Dr. Slade was in a solo, referral-based, minimally marketed private practice in the pro- cess of shifting from "LASIK major, minor cataract" to "cataract major, minoring in LASIK" that had a high rate of premium IOL conversion. He was, he said, intrigued by the laser as a way to continue that pathway of growth. With this background, Dr. Slade was ideally positioned to provide an overview of femtosecond laser cataract surgery's history at a sympo- sium on "Four Years of Femtosecond Laser-Assisted Cataract Surgery" held on the morning of the last day of the 2016 ASCRS•ASOA Symposium & Congress. Dr. Slade said that femtosec- ond laser-assisted cataract surgery (FLACS) was first conceived as a potential answer to the question, "Is cataract surgery good enough?" Against the background history of the then more than 20 years of View videos from ASCRS•ASOA 2016: EWrePlay.org Elizabeth Yeu, MD, discusses the highlights of the Young Eye Surgeons sessions. continued on page 86 View videos from ASCRS•ASOA 2016: EWrePlay.org David Chang, MD, reviews different technologies for an automated capsulotomy.

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