July 2015




Femto cataract clinical update

Femtosecond cataract laser upgrades

by Ellen Stodola EyeWorld Staff Writer

femtosecond laser

A round and centered femtosecond laser-created capsulorhexis with a nicely positioned implant is the main reason for FLACS success, according to Dr. Yeoh. Source: Ronald Yeoh, MD

Surgeons in different countries share their experiences adopting the femtosecond laser into practice

The experience of incorporating the femtosecond laser for cataract surgery into practice has been different for surgeons around the world. Michael Lawless, MD, clinical associate professor, University of Sydney, and ophthalmic surgeon, Vision Eye Institute, Sydney, Australia; Arthur Cummings, MD, Wellington Eye Clinic and Beacon Hospital, Dublin, Ireland; and Ronald Yeoh, MD, consultant eye surgeon and medical director, Eye & Retina Surgeons, Singapore, spoke about the introduction and adoption of femtosecond laser cataract surgery in their experience.

Adoption of femto

Dr. Lawless was the first surgeon to introduce the femtosecond laser to Australia in April 2011. In the first 2 years, the number of femtosecond lasers available increased more quickly than I would have anticipated so that there were more than 20 units installed, allowing access to the technology in almost all major cities, he said. However, Dr. Lawless said, after 2013, the number of installations stopped and did not expand in the way that he thought they would.

Back in 2011, I thought there would be a slow up-take but then it would build momentum so that it became a very commonly performed procedure, he said. Within Australia approximately 6% of cataract and refractive lens procedures are performed with the femtosecond laser, and this mirrors very closely the percentage of multifocal lenses used within the country as well. In Dr. Lawless personal practice, he has been using the femtosecond laser for the majority of his cataract cases since 2011. Currently I use it in 95% of cases, and the 5% where it is not used are mainly financial impediments or less commonly technical reasons, he said. Additionally, he thinks that in certain cases, like with Fuchs dystrophy, pseudoexfoliation, or white cataracts, it provides a clear advantage in safety. I think this increase in safety for an individual patient applies across the spectrum of cataract and lens surgery, so for that reason I offer it to everybody. Meanwhile, femtosecond laser- assisted cataract surgery (FLACS) arrived in Singapore in 2012, Dr. Yeoh said, with 2 machines purchased and placed in private hospitals and 2 additional purchased and placed in institutions.

Interestingly, the volume of FLACS has been significantly higher in institutional practice than in private, he said. I ascribe this trend to the presence of more cutting-edge cataract surgeons in the institutions than in the private sector. Some of the private surgeons are reluctant to learn and embrace a new, expensive procedure that has not yet been proven superior. I have practices that straddle both these sectors and perform FLACS at each location equally, as I believe the technology yields better results, Dr. Yeoh said.

In Ireland, however, the femtosecond laser is not yet being used for cataract surgery. Dr. Cummings attributed this to insurance companies because currently the laser is not a covered procedure and copayments are not permitted. Although he is using the femtosecond laser for other procedures, like femtosecond LASIK and for intrastromal pockets and some corneal rings, the lack of insurance coverage and the ability to copay are the real obstacles in the adoption of femtosecond laser-assisted cataract surgery in Ireland, he said.

Specific challenges in different countries

Dr. Yeoh said that the biggest challenge is the cost of purchase and the click fee, which he said makes the surgery 25% more expensive than standard phaco.

Dr. Lawless said he sees no specific challenges with the femtosecond laser.

Really the only challenge is ready access to the technology and having the technology in place in a hospital or day surgery center that you routinely operate, he said. There are no installations in major teaching hospitals so ophthalmology trainees [registrars] do not gain practicable experience through their training program, and I think this is a shame but is a pattern that is mirrored around the world.

Reimbursement of FLACS Laser upgrades article summary

In Australia, there is no reimbursement for the laser portion of femtosecond surgery, Dr. Lawless said. There has been a pattern of copayment for many years so that if a patient wishes to have cataract surgery performed privately, part of the surgical fee comes from the federal government system [Medicare] and part of it is paid by the patients health insurance, and the patient tops up the rest, he said. Because patients have been used to a copayment system, when they go privately for surgery, the LenSx (Alcon, Forth Worth, Texas) is one more copayment, so it is not an unfamiliar setting for patients, he said. In Singapore, Dr. Yeoh said, patients pay for the use of the femtosecond laser on their own, and he added that those who are insured will usually be reimbursed by their healthcare providers.

Advantages and disadvantages

Dr. Cummings said that the literature on femto is not yet showing that its better than phaco. Patients like the idea that femto can make a repeatable capsulorhexis every time, he said, but they really care about how they will see compared to someone who had regular phaco. The benefits dont currently justify getting the device when it means the patient is going to pay for the entire procedure rather than just for the copay, he said. But theres no question that in time it will be the way its done. He believes that it will make sense to use the femtosecond laser when there are lenses specifically made for femto and for a perfect rhexis. The femtosecond laser gives better positioning of the capsulorhexis and softens the lens, he said. I personally think it will take off when lenses come onto the market that have been designed specifically for femto phaco. The advantages of the femtosecond laser are well documented, Dr. Yeoh said, including rounder and more precise capsulorhexes, lower ultrasound energy usage, and more consistent incisions. These, however, have not translated to more precise refractive outcomes, he said. Most surgeons agree that while the jury is still out on the refractive benefits of FLACS for standard cataracts, the advantages in complex cataracts like dense nuclei, subluxated lenses, fibrotic cataracts, and posterior polar cataracts are obvious. Apart from the cost of the procedure, the only other issues that may be faced are the greater length of time for surgery and greater space requirement, Dr. Yeoh said. New surgeons will also need to modify their surgical technique. Its my firm belief that if cost was not an issue, many surgeons would take up FLACS, he said.

Dr. Lawless thinks that the major advantage of FLACS is that it is safer. The capsulotomies with current technology and techniques are round, centered, and robust, he said. My anterior capsular tear rate compares favorably to manual surgery, and I have published on this. Additionally, the nuclear fragmentation means the time inside the eye with phacoemulsification is less, and less energy is used with less manipulation.

Corneal incisions are the least useful part of the technology, Dr. Lawless said, but he performs them routinely, occasionally opening them with a blade. The safety that is conferred by the capsulotomy and lens fragmentation is obvious to a surgeon who uses this technology frequently, he said. The only disadvantage is cost to the patient.

Changing technique

Dr. Lawless said that the femtosecond laser has changed his phaco technique. I was always a prechopper in the Akahoshi mode prior to femtosecond surgery, and I still prechop, but these days with a blunt prechopper, he said. I am a person who likes a stable anterior chamber, so I am lucky that I have the Centurion system [Alcon] to allow me to achieve this. Dr. Lawless added that he has slightly modified his cortical aspiration to remove the cortex in a more peripheral fashion.

He finds this to be quick and efficient. Overall, the femtosecond laser has led to less intraocular trauma and quieter, more comfortable eyes, he said. I no longer use the astigmatic incisions with the femto laser, preferring instead to use toric IOLs down to low levels of astigmatism as they are more predictable than even a laser incision can be. Dr. Yeoh uses the femto prechopper to complete nucleus separation in most cases of femto- fragmented nuclei. Since getting comfortable with using the femto prechopper, I am now using a regular prechopper for nuclear division in many of my routine non-FLACS softer cataracts, he said. Additionally, a greater appreciation of a round and well-positioned femto CCC has led him to try harder to achieve the same with the manual CCC technique.

Editors note: Dr. Cummings has financial interests with Alcon. Dr. Yeoh has financial interests with Alcon (Fort Worth, Texas), AMO (Abbott Park, Ill.), and Bausch + Lomb (Bridgewater, N.J.) Dr. Lawless has no financial interests related to the article.

Contact information

: abc@wellingtoneyeclinic.com
Lawless: Michael.lawless@visioneyeinstitute.com.au
Yeoh: ersryeoh@gmail.com

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