Eyeworld

EW CATARACT 34 May 2017 Research highlight by Maxine Lipner EyeWorld Senior Contributing Writer has been upgraded all the time," he said. "I think the complication rates will go down as the technology improves." He cites relatively minor complications like docking that doesn't work or cases where there is slightly eccentric fixation that are likely to improve. In general, both the conventional and the femto-as- sisted approach are already very safe, he notes, adding there's nothing that says the femtosecond produces significant complications. Dr. Rosen views the femtosec- ond-assisted approach as exciting technology that has not yet reached its full potential. "I think we're in the early days," he said, adding he believes many assume the technol- ogy is up and fully ready, but it has only been available for around 4 or 5 years. "It's an evolution—it's looking for a place in cataract surgery," he said. Already this has several advan- tages, he believes. "I think that it's an enabling technology, which says that we can use different types of lens implants," Dr. Rosen said. "I think that it makes the surgery less variable and can raise everyone's surgery to the same level." All this points to a role in complex cataracts or possibly improving the productiv- ity of cataract surgery, he believes. Overall, the evolution process continues. "I think people assume what we've got now is the final fully developed product and it's going to be immediately perfect, but what I don't think most people appreciate is that [conventional] phaco was first done in the 1970s and wasn't universal in Europe until the early 1990s, after it had gone through several evolutionary stages," Dr. Rosen said. "We're really just starting off on the [femtosecond-assisted] journey—we're not even halfway along." EW Reference 1. Manning S, et. al. Femtosecond laser-as- sisted cataract surgery versus standard phacoemulsification cataract surgery: Study from the European Registry of Quality Out- comes for Cataract and Refractive Surgery. J Cataract Refract Surg. 2016;42:1779–90. Editors' note: Dr. Rosen has no finan- cial interests related to his comments. Contact information Rosen: phrosen@rocketmail.com come," he said. "So, I think that the surgery is probably more reproduc- ible, but at the end of the day it doesn't mean that the patients read down the vision chart any better— they tended to see the same." Evolving approach Still, in Dr. Rosen's view there are situations where use of the femto- second-assisted approach could be helpful. "I think it's a very interest- ing technology, very sophisticated, and I think it does have potential," he said, adding that because cata- ract removal is more reproducible with the femtosecond laser, it raises the overall standard of the surgery. While a very good surgeon could probably attain the same results, if someone creating a capsulorhexis finds it more challenging, then the femtosecond laser can help to raise that standard, Dr. Rosen explained. Or, with a lens for which capsulor- hexis centration is important, this becomes an enabling technology, he continues. In addition, he views the fem- tosecond technology as something that has the potential to improve productivity in cataract removal but observed that this remains to be proven. In fact, the femtosecond-assist- ed technology is still evolving, Dr. Rosen stresses. "The algorithms and the software that drives the lasers cataract cases performed using the conventional approach. When investigators compared the two groups, they determined that the outcomes were fairly equivalent. "Essentially there was no clinical difference between the two procedures in a real-world setting," Dr. Rosen said. While there was some suggestion that the compli- cation rates were different in the femto-phaco group, essentially the clinical outcomes were the same, he stressed. With the femtosecond-as- sisted approach, patients were deter- mined to be within 0.43 D of target versus a mean of 0.40 D for those in the conventional group. Also, investigators found that in terms of corrected distance acuity, this was actually a bit lower in the femto- second by about 5 letters or more. In terms of postoperative complica- tions, investigators found that for the femtosecond laser group, this was at 0.7% versus 0.4% for the con- ventional approach. These findings were in keeping with expectations of the femtosec- ond-assisted approach, Dr. Rosen noted. "The preliminary studies showed that it could be more accu- rate and you achieve a better circular capsulorhexis, possibly better lens centration, and less phaco time. These are small improvements, but they don't necessarily contribute to a significantly better visual out- Conventional phacoemulsification and femtosecond laser-assisted surgery square off O ver the last few years, many practitioners have begun to examine the use of femtosecond laser technology in conjunction with cataract surgery to hopefully further enhance results. But can this technology really make a difference in procedure outcomes? This is what investigators in a study published in the December 2016 issue of the Journal of Cataract and Refractive Surgery set out to consider, according to Paul Rosen, MD, Oxford Eye Hos- pital, Oxford University Foundation Trust, Oxford, UK. 1 Comparing techniques Investigators were spurred by the buzz about the femtosecond pro- cedure to consider how the two procedures compared. "There was a lot of excitement that it was going to be the next best thing for cata- ract surgery," Dr. Rosen said. Then clinical studies started coming out that suggested perhaps it wasn't much better than standard phaco, he continued. Investigators had access to the European Registry of Quality Outcomes for Cataract and Refractive Surgery database of phacoemulsification cases, Dr. Rosen noted, adding that they viewed this as an opportunity to both use this resource, which contained informa- tion on routine cataract surgery, and to prospectively collect data on the femtosecond approach. Using the information in the database as a comparison group for the study, investigators also recruited a number of centers that had been conducting femto-assist- ed phacoemulsification for a long enough time to have become good at it, Dr. Rosen explained. "They agreed to supply their data on the European Registry of Quality Outcomes for Cataract and Refrac- tive Surgery database so we could compare the two groups," he said. "They were matched for age and various other parameters." Ultimate- ly included in the study were 2,814 femtosecond laser-assisted cases, which were compared to 4,987 Evaluating cataract outcomes Dr. Rosen believes femtosecond-assisted technology is still in its early stages. Source: Paul Rosen, MD

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