July 2015




Femto cataract clinical update

The evolution of laser cataract surgery

by Lauren Lipuma EyeWorld Staff Writer

Evolution of laser article summary

Laser cataract surgery: A timeline

Laser surgery timeline

Laser surgery evolution

Advances in laser technology and changing physician attitudes have fueled the growth of this premium procedure

Over the past 50 years, physicians have found ways to use lasers in almost every area of ophthalmologyfrom repairing tears in the retina to creating corneal flaps and treating glaucoma. Using lasers in cataract surgery seems a natural step, but for a laser to supplement or replace such a successful manual procedure, the technology has to be just rightand so does the timing. Now, for laser cataract surgery, it seems that these criteria are close to being met. Since the first laser-assisted cataract procedure was performed 7 years ago, the technology has evolved dramatically, patients have embraced it, and more physicians than ever are adopting it. Here, 4 laser cataract surgery pioneers share their experiences watching this procedure evolvetheir triumphs, challenges, and views on where laser cataract surgery will go in the future.

Recognizing the lasers potential

Zoltan Nagy, MD, clinical professor of ophthalmology, Semmelweis University, Budapest, Hungary, performed the first laser cataract procedure in the world, and Stephen G. Slade, MD, Slade & Baker Vision Center and Laser Center of Houston, performed the first procedure in the U.S. Both surgeons immediately recognized that the femtosecond laser had the potential to transform cataract surgery. This one just seemed to make total sense to me, Dr. Slade said. It seemed to be a great way to use the laser. In all surgeries, the less you do, the better it is for the patient, he said, and laser cataract surgery allows him to spend less time inside the eye, using fewer instruments and less fluid. I think it provides surgery that is more elegant and a gentler surgery for the patient, he said. Some people say that it makes the surgery easier, and it can, but in no way do I think its a crutch for lesser surgeons. I think its made me a better surgeon. I felt the same excitement performing the first capsulotomy and fragmentation as I did when I started refractive surgery in 1992, Dr. Nagy said. The aim of femto laser-assisted cataract surgery is to achieve predictability and safety results similar to those we have achieved already in refractive surgery. This technology is not replacing good surgeons, it is helping good surgeons to achieve even better refractive results. Jonathan Talamo, MD, director, Massachusetts Eye and Ear Infirmary Waltham, Waltham, Mass., believes the biggest benefit of laser cataract surgery is that it provides consistent and predictable results. It makes surgery easier and more predictable for, if not every cataract surgeon, the majority of us, he said. Whether its a young patient with elastic tissues, a very hard nucleus, or a patient with compromised zonules from a genetic condition like pseudoexfoliation, the laser really shines in making the difficult cases routine and the impossible cases possible.

The initial challenges

The early days of laser cataract surgery were filled with issues that needed to be worked out, from increasing the accuracy of the laser cuts and OCT image quality to optimizing the software and patient interface. Dr. Slade recalls the early days of using the laser as times of trial, error, and modificationmaking small changes to the software, patient interface, and OCT after each case until the laser cuts were just right. Initially, the capsulotomy and fragmentation went well, but corneal cuts were more central than expected based on the OCT and surgical screen images, causing more surgically induced astigmatism (SIA) than anticipated, Dr. Nagy said. After analyzing the possible causes, Dr. Nagy and the laser physicists concluded that the patient interface needed to be redesigned. A lot of work was done until we found the current SoftFit interface [Alcon, Fort Worth, Texas], which provides better corneal wound structure, less postoperative conjunctival redness, and in 97% of cases, a free-floating capsulotomy, he said. Robert J. Cionni, MD, medical director, The Eye Institute of Utah, Salt Lake City, started performing laser cataract surgery with the first commercially available LenSx laser (Alcon) in 2011. Initially, capsulotomies and lens chop were not always complete, he said, but that changed as the technology advanced and patient interfaces improved. The pristine, strong capsulotomies that lasers produce now and the ability to use little to no ultrasound for lens removal are clear advantages when dealing with mature cataracts and cases where there is zonular compromise, he said. Dr. Talamo felt that the early patient interfaces were not as user-friendly as they needed to bethey were harder for the surgeon to use and uncomfortable for the patient. Docking time was also an issue. With the first lasers, it took about 57 minutes to position the patient, dock the laser to the eye, and deliver treatmenta length of time that was manageable, but not ideal. As the interfaces evolved, however, they have become more sophisticated, easier to use, and more comfortable for the patient, dramatically reducing docking times. Now, the time from when I walk into the room until I exit the room is under 2 minutes, with the actual laser time being less than 30 seconds, Dr. Cionni said.

The pace of adoption

Ophthalmic surgeons have always had some skepticism regarding new technology and some level of resistance to change, even with technologies considered indispensable today, such as phaco and even IOLs. In the operating room in particular, our existence is very stylized and repetitive, and thats probably a good thing because thats how [we] make sure that care is delivered in a reproducible and highly safe and effective manner, Dr. Talamo said. When you have anything that takes a surgeon and his or her team out of their comfort zone and introduces new workflow patterns and new skills to master, that always gets pause. Laser cataract surgery has seen its share of skepticism, and in a way, that makes sense, Dr. Talamo saidwhen you take a highly evolved, efficient procedure and add expensive capital equipment that disrupts the workflow, skepticism is to be expected. While the pace of laser cataract surgery adoption discourages some physicians and those in industry, Dr. Talamo does not feel this way. When you look back at what happened with the transition from manual extracapsular cataract surgery to phacoemulsification, that transition took a lot longer, and I would argue [it] encountered many more bumps in the road than the introduction of laser cataract surgery, he said. I think that we are on or ahead of course for seeing the technology thats going to become widespread and mainstream in our work life in the years to come. The economics of laser surgery are still an issue for many surgeons, but surprisingly, patients have quickly embraced the technology, despite the added costjust as they embraced it for refractive surgery. What lasers had done for LASIK surgery is make flap cutting safer and more predictable, Dr. Talamo said. It took some time for the refractive surgery community to come around to that idea, but interestingly, very quickly, patients gravitated toward it. They intuitively understood the concept of using lasers in medicine and surgery. To Dr. Slade, the biggest benefit of the technology is that it has limitless potential. To me, this is an enabling tool, he said. Theres only so much you can do with a metal blade. But when you go into a digital area, the sky is the limit.

Editors note: Drs. Cionni, Nagy, and Slade have financial interests with Alcon. Dr. Talamo has financial interests with Abbott Medical Optics (Abbott Park, Ill.) and Alcon.

Contact information

: 801-266-2283
Nagy: nz@szem1.sote.hu
Slade: sgs@visiontexas.com
Talamo: jtalamo@lasikofboston.com

The evolution of laser cataract surgery The evolution of laser cataract surgery
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