SEP 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

Issue link: https://digital.eyeworld.org/i/82503

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Page 57 of 103

58 EW FEATURE February 2011 Refractive cataract surgery September 2012 On the edge of by Michelle Dalton EyeWorld Contributing Writer private practice, Drs. Fine, Hoffman & Packer LLC, Eugene, Ore. "I'm proud of my capsulorhexis and I've spent a lot of time working on it. But [the LensAR] is better, and it's better every single time." Likewise, the ability of the laser to center the capsulorhexis on the corneal apex or pupil center is something Dr. Packer said he's unable to do manually. "I had heard about the advances in precision and reproducibility of the various steps, but actually using it and seeing it in action noticeably exceeded my expectations," said Gary J.L. Foster, M.D., in private practice, Eye Center of Northern Colorado, Fort Collins. Dr. Foster has been using the LenSx (Alcon, Fort Worth, Texas) since August 2011. The arcuate incisions and the capsulorhexis are "freakishly per- fect" under the slit lamp, he said. Dr. Packer believes the cataract Early believers in femtosecond laser for refractive cataract surgery say this is just the beginning A utomated machines will always produce more con- sistent results and be able to do so quicker than performing the same chores manually. In the case of fem- tosecond lasers for refractive cataract surgery, though, is that enough to warrant the investment? EyeWorld asked four leading cataract surgeons involved with the development of these lasers what attracted them to the technology and why they were among the first converts. While it would be difficult to argue that current cataract surgery is AT A GLANCE • Femto-phaco creates a perfect capsulorhexis every time • Because the capsulorhexis can be placed anywhere, effective lens position will improve • Learning curves are shorter for refractive surgeons than cataract surgeons but are not lengthy • This first generation group of femto-phaco lasers is just the beginning extremely effective, "there are some shortcomings, and the femtosecond laser is reducing the number of vari- ables in our procedures," said Sheraz M. Daya, M.D., consultant and medical director, Centre for Sight, West Sussex, U.K. For instance, manually dividing a lens can put stress on zonules; the Victus laser (Bausch + Lomb/Technolas, Rochester, N.Y./Munich, Germany) can perform the same procedure "almost identically from case to case," Dr. Daya said. Jonathan H. Talamo, M.D., associate clinical professor of ophthalmology, Harvard Medical School, and medical director, Surgisite Boston, likens the fem- tosecond lasers in cataract surgery to the early femtosecond lasers developed for refractive surgery. "Those early devices weren't doing something we couldn't do ourselves," he said. "But they added precision and accuracy." Dr. Talamo has been involved in developing the OptiMedica Catalyslaser (Sunny- vale, Calif.) since 2007, and said these lasers achieve "greater preci- sion with greater accuracy than manual techniques, and that will lead to greater safety." Regardless of how fast a cataract surgeon can operate, "the machine will always be faster and more con- sistent," said Mark Packer, M.D., clinical associate professor, Oregon Health & Science University, and in fragmentation capabilities of the lasers will translate into better safety. "I'll have to do 1,000 cases before I can prove it's safer, but I believe that laser phacofragmentation reduces endothelial cell loss and helps avoid capsule rupture," he said. The "A-ha" moment While all of the femtosecond lasers have proprietary features, each is capable of creating a perfectly round capsulorhexis the surgeon can place wherever he or she desires. "For me, the Eureka moment was the first time I operated with one of these machines," Dr. Talamo said. "It was the moment I realized the cataract surgery was half done before I even touched the patient. Even an execellent surgeon has a dominant hand and dominant side, and on the other side, it's harder to get inside the eye and make a perfect capsulorhexis." Because the capsu- lorhexis can be centered on the pupil, on the capsular bag, or rela- tive to the cornea, surgeons have significantly more control over where the IOL inevitably sits. "I may be wrong in attributing that to the laser's capsulorhexis, but that's what the data is showing us so far," Dr. Talamo said. He worked with OptiMedica to develop liquid optics because other contact devices "didn't work quite as well in my hands." Dr. Packer said the imaging sys- tem of the LensAR (Orlando, Fla.) is what set it apart from the other sys- tems, and as a result, "the ability to address dense cataracts is astonish- ing." When he used the laser to treat dense cataracts in Peru, the laser "cut really deeply, close to the poste- rior capsule. The LensAR can break through that dense posterior plate other systems using optical coher- ence topography (OCT) imaging are not able to do." The Victus is "a total anterior segment workstation," Dr. Daya said. "It can't do it all yet, but it can make the capsulotomy, lens fragmenta- tion, flaps, astigmatic keratometry, and can make all the incisions." Dr. Daya's "Eureka" moment is what these lasers are capable of doing in the future. "We're entering the 'era of Star Trek,'" he said. "When we first started LASIK, we thought those excimer lasers were high-tech—and look where we are now. I see the same things happen- ing with cataract femtos." Dr. Packer added his first surgery with the femto took less than 2 min- utes of suction time, but might take closer to 3 in eyes that are very small or tight. "I feel femtosecond cataract surgery is already a better procedure than traditional cataract surgery, and the femtosecond approach and technology is improving at a much faster rate than traditional, so the gap is growing," Dr. Foster said. Inherent advantages to refractive surgeons? Femtosecond cataract surgery is a different type of surgery, and tradi- tional cataract surgeons need to learn to play to the laser's strengths instead of trying to force the laser to conform to more traditional surgery, Dr. Foster said. "We're operating on pressurized lenses," he said. "Some of our maneuvers and techniques need to adjust." It is an easy learn- ing curve, but allowances need to be made for learning the new tech- niques. A refractive surgeon who is comfortable with femtosecond tech- nology will find the transition to femtosecond cataract surgery rela- tively easy, but for traditional cataract surgeons, the femtosecond laser "is a whole new ballgame," Dr. Daya said. Using the suction ring and docking patients may be an initial challenge for some, he added.

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