Bladeless Cataract Surgery: “We have this ‘Laser’…”

13 02 2013

We are in the midst of a surgical evolution and many of us don’t even know it yet.  This is a ‘giant leap for mankind’ type of moment for eye surgeons globally, but more importantly for patients.  Femtosecond laser guided by optical coherence tomography is the newest innovation in modern cataract surgery.  Instead of  using a blade to create incisions, break up the lens and correct astigmatism, the femtosecond laser has leaped from being a purely refractive tool used in LASIK to a surgical sous-chef of sorts.   Currently OptiMedica Catalys (Optimedica Corp, CA, USA),  Alcon LenSx (Alcon Laboratories, Ft Worth, TX, USA),  LensAR (LensAR Inc, FL, USA) and Technolas (Technolas Perfect Vision GmbH, Germany) are the only commercially available cataract products.

Femto became popular in 2001 when it began to replace the microkeratome blade used to create the corneal flap during LASIK (Laser Assisted in-Situ Keratomileusis).  It was marketed to the masses as ‘bladeless lasik,’ winning the relief of patients fearing the blade traditionally associated with surgery.  It also became quickly adopted by many refractive surgeons due to its high repeatability and precision yielding a decrease in flap complications and an increase in visual outcomes.

Capsulorhexis 

Femtosecond cataract surgery has now emerged as a means of fragmenting the lens, creating the anterior capsulotomy and performing any corneal incisions required for the procedure including LRIs forastigmatic corneas.  Creating the capsulotomy in a highly precise and accurate manner allows for proper centration of premium toric or multifocal IOLs.  So far, several studies (Freidman,2011) have demonstrated that femto is at least as good as manual capsulorhexis and the incidence of capsular tears may in fact be lower when you factor in surgical teaching institutions.  Theoretically controlling the shape and size of the capsulotomy while minimizing complications (capsular tears) will allow the surgeon to achieve highly repeatable outcomes which greatly enhances his or her ability to fine tune the procedure to maximize visual outcomes.

Courtesy of Review of Ophthalmology

Phacofragmentation

Lens fragmentation is also improved in that the energy required to break up the lens is decreased anywhere from 50-96% (Naranjo-Tackman R, 2010 and  Edwards K,2011).  Less energy during phacofragmentation means less potential trauma during the surgery itself and therefore a lower incidence of post-surgical or peri-surgical complications.  To the after care doctor, this means a faster visual recover and less adverse events.  To the patient this means a happier healthier surgical experience.

Corneal Incisions

LRI or Limbal Relaxing Incisions are arcuate incisions made by the surgeon to correct corneal toricity.  This technique is considered a premium add-on to traditional cataract surgery and with femto this premium technique has made quite an impact.  The length, depth and angle are guided by anterior segment OCT.  This information is used in the femto-assisted astigmatic keratotomy to provide a very specific cut under the epithelium which can decrease astigmatism up to 1.5 diopters (Kymionis, 2010).

Is there a downside?  Yes.   Two.  Clinically, subconjuctival hemorrhages are reported due to the negative pressure applied to the eye during the procedure.  This typically resolves within a few weeks and doesn’t have any visual effects or pain associated.  The second, and the more obvious downside is the cost – both to the surgeon and to the patient.  With every new technology comes cost and somebody has to pay and with a half-million dollar price tag someone definitely is.  Being extremely new to the ophtalmic world, this premium will cost an average Canadian ~$3500 per eye so one needs to consider the pros and cons mentioned above.

From a clinical perspective the theoretical and real advantages to femto are currently developing but all evidence is pointing to reduced adverse events and better visual outcomes.  Patients will invariably ask – “How much better?” and there are varied statistics being reported by the various manufacturer sponsored studies most common being 60% of patients with traditional surgery achieving 20/20 while 90% with laser (Kránitz K, 2011).  However peer-reviewed scientific data is still lacking in general as to whether this is truly value added.  How will it change the landscape of next generation surgeons in training?

One could argue that the ‘hands-off’ approach to cataract surgery with femto will create a preference among younger surgeons to steer away from manual phaco.  Scleral incisions aren’t performed routinely anymore and a higher number of surgeons use clear corneal incisions (CCI) for good reason.  But as more surgeons become increasingly comfortable with laser cataract surgery and less so with manual, how effectively will complicated cases be managed where a manual intervention is required?   A natural inflation will create the demand for this technology by new surgeons which will invariably end up at cost to the patient and the added cost for 1-2% benefit has some surgeon’s hesitant to slide down this slippery slope.

There has also been some debate as to the role of optometry in this evolution.  In some high volume surgical practices, the added time of using the laser has decreased their caseloads and therefore efficiency.  The possibility of training optometrists in some US states has emerged, which would allow OD’s to perform the initial femto-guided portion of the surgery with the MD would take over for aspiration and implant positioning.  Of course significant training and mounds of legislative battles will hold this item in question for years, but think about how all changes in scope of practice began.  Regardless of the optometrist’s future role, currently it is critical to be aware of the ups and downs of femto cataract surgery and temper the marketing behind it.  Already there have been advances in this technology with real-time OCT guidance for next generation instruments.  Personally I see this as a great surgical step which needs to be managed judiciously by those providing  and managing it.  We did take an oath after all!

Dr. Richard Maharaj OD, FAAO

Director of Optometry,

eyeLABS Inc.

www.eyelabs.ca

twitter: @eyelabsinc

rmaharaj@eyelabs.ca

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