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55 EW FEATURE December 2016 • Highlights from ESCRS 2016 handpiece. It has a max energy of 10 mJ, a wavelength of 1,064 nm, a pulse energy of 3 mJ to 10 mJ, and a pulse length of 5 nanoseconds. There were several paper pre- sentations at ESCRS focused on the nanosecond laser, including the one by Dr. Vryghem. His study involved 141 patients who had nanosecond laser cataract surgery and received a trifocal IOL. Dr. Vryghem said postop day 1, the eyes seemed calm and these patients appeared to have faster visual recovery; average endo- thelial cell loss was 6.9%. Gangolf Sauder, MD, Mannheim, Germa- ny, presented on a randomized prospective study that compared nanosecond laser cataract surgery to traditional phacoemulsification surgery. Dr. Sauder said there was similar endothelial cell loss in both groups, but the nanosecond laser group had 2.7% endothelial cell loss at 1 year postop compared to 7% in the phaco group. Anja Liekfeld, MD, Berlin, Germany, described her results of using nanosecond laser in 100 con- secutive cataract patients and said at the meeting she had to convert to phacoemulsification in three patients. This, she clarified later, was because the surgery was beginning to take too long with the nanosecond laser and she felt converting to phaco to speed it up was safer for the patient. Dr. Liekfeld said her results did not show a correlation between endothelial cell loss, which was an average of 2.2%, compared to energy used. Overall, Dr. Liekfeld said in her presentation that they found nano- second laser cataract surgery "at least as good and as safe as the 'gold standard.'" Two studies published earlier this year suggest nanosecond laser cataract surgery results in lower en- dothelial cell loss and faster corneal thickness recovery compared to phacoemulsification surgery. Tanev et al. performed cataract surgery in the eyes of 41 patients where one eye received nanosec- ond laser cataract surgery, and the contralateral eye received ultrasound phacoemulsification. 1 Endothelial cell density was compared before and after cataract surgery. The researchers found better endothelial cell preservation in the eye operated on with the nanosecond laser. A separate study that evaluated femto phaco surgery compared to nanosecond and femtosecond laser cataract surgery—considered "all laser" cataract surgery—found the increase in central corneal thickness was lower in the latter group. 2 Eyes that underwent "all laser" cataract surgery also showed less endothelial cell loss. Ivan Tanev, PhD, assistant pro- fessor, Department of Ophthalmolo- gy, Medical University of Sofia, Sofia, Bulgaria, said in the last 2 years he EyeWorld Monthly Pulse EyeWorld Monthly Pulse is a reader survey on trends and patterns for the practicing ophthalmologist. Each month we send an online survey covering different topics so our readers can see how they compare to our survey. If you would like to join the hundreds of physicians who take a minute a month to share their views, please send us an email and we will add your name. Email carly@eyeworld.org and put "EW Pulse" in the subject line. Poll size: 104 continued on page 56 has increased his use of nanosecond laser to 70% to 80% of his cataract procedures. Dr. Tanev has attached the Cetus to the Millennium Mi- crosurgical System (Bausch + Lomb, Bridgewater, New Jersey), Stellaris PC (Bausch + Lomb), VISALIS 500 (Carl Zeiss Meditec, Jena, Germany), and Oertli (Berneck, Switzerland) and Geuder (Heidelberg, Germany) surgery platforms. "Virtually any cataract up to 4+ nuclear sclerosis can be done with the system," he said. "The system fits a wide variety of cases, for example, some compromised cor- neas [like] Fuchs' dystrophy cases, limbal deficiency corneas. I'm not a femto surgeon, but it looks like the nanosecond laser perfectly matches the needs of a low energy [emitting] device to finish the femto pre-cut cataract." Dr. Tanev said he thinks the complication rate of cataract surgery with nanosecond lasers is lower than that with standard ultrasound phacoemulsification, but, he added, "it is crucial to understand how the nanolaser works and what to expect from it." "The surgical gestures and habits look like in the normal phaco [system]," Dr. Tanev said. "Of course, you should follow some learning curve and adapt [your] personal surgical habits to nanosecond laser surgery." For example, Dr. Vryghem had been told it was impossible to rup- ture the capsule with the nanosec- ond laser system, but he found this not to be the case. "I was possibly too aggressive and I ruptured some capsules, about eight since I got the machine in August [2015], but five of these were in the beginning. The last capsule rupture I had was [more than] 6 months ago," he said. Overall, Dr. Vryghem said the nanosecond laser is an "affordable marketing tool" to differentiate one's practice, but do surgeons really need it? No, he said. Dr. Vryghem said he doesn't try too hard to sell his patients on opting for nanolaser technology but might advise them more on it if they are at risk for fur- ther endothelial cell loss. "If the patients have the choice to go for nanosecond laser cataract surgery or not, only one patient in five chooses it. I [tell patients], you can do it, but you don't make a mis- take if you do ultrasound," he said. Still, he said he's pleased with the edge the technology gives his practice. "It's much less costly, the dispos- ables are less costly, and at least I'm doing the real laser cataract surgery," he said, adding that it also takes up less space than femtosecond lasers, weighing 12 kg.

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