EyeWorld Asia-Pacific December 2012 Issue

December 2012 11 EWAP Feature forms a path of least resistance so the incision doesn’t spread open immediately. It’s still attached so you can go back later and deepen it to get a greater effect. That’s something you can’t do with a blade.” Drs. Culbertson and Talamo believe nomograms tailored to the femto technology will make astigmatic incisions even more effective. “The establishment of nomograms will be a bit difficult, but it can be done. We just need to get a large enough number of patients to use it,” Dr. Culbertson said. LensAR experience LensAR’s 510(k) submission for corneal incisions is currently being reviewed by the. FDA for its corneal incisions this year, said Mark Packer, MD , clinical associate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, Ore., USA. Dr. Packer and other surgeons have used the laser abroad, including having recent experiences in Latin America. Dr. Packer expects the use of the laser for astigmatism treatment will offer some benefits. “The drive toward greater accuracy and predictability in the outcomes of our incisional surgery for astigmatism represents a tremendous benefit for our patients, who will be able to get the desired results with a single procedure,” Dr. Packer said. “Ultimately, our abilities to titrate and enhance precise limbal relaxing incisions [LRIs] may prove superior to outcomes achieved with toric IOLs for most degrees of correction.” He described fundamental ways in which LRIs created with femtosecond lasers are different than blade-based LRIs. First, the laser should make placement of the incisions easier. “Successfully placed LRIs reduce the patient’s cylinder without an overcorrection or axis shift. Determining the exact location of the cylinder is often challenging,” he said. Femtosecond technology seems to indicate a more precise manner for incisional correction of astigmatism, including high degrees of astigmatism in post- keratoplasty eyes, Dr. Packer said. “Common sense suggests that automating the incisional technology and thus eliminating the variability in performance, which is an ineradicable attribute of manual incision construction, will lead to greater reproducibility and less variation in results,” Dr. Packer said. Placement of LRI incisions should also be more predictable with femto technology, Dr. Packer added. “The potential for laser LRIs includes the ability to place the photodisruptive cutting effect at precisely the right orientation and to make cuts of the correct length and depth to create the desired refractive effect.” LenSx experience The diamond LRI blade is going the way of the old RK blades as they are replaced with something better. Gary Foster, MD , Eye Center of Northern Colorado, Fort Collins, Colo., USA, prefers to use the LenSx laser to address astigmatism in as many patients as possible. “I prefer to use it on all my cataract patients with astigmatism, whether they choose a multifocal IOL, a toric, or standard monofocal with an Internal audits Dr. Foster recommended surgeons evaluate all the lasers and choose the one they believe has the best technology and the deepest ongoing commitment to research, service, and improving outcomes. After a year of commercial use, “the number of patients we’re treating with the LenSx is double what we anticipated. In retrospect, we worried too much about capitalizing the laser when we should have spent more time considering how to educate patients about the opportunity.” Dr. Talamo’s group has been actively evaluating the lasers for the past year and will likely proceed with an acquisition “soon,” and advises other centers to evaluate whether they believe in the technology, determine affordability and workflow processes, and determine a marketing strategy. “If you don’t think you can do more than a couple hundred cases a year, paying for the technology is going to be difficult,” he said. The next stage of development may involve using different implants that may fill the bag with a particular type of polymer—“the options are unlimited because of what this technology can bring. We’ve got more options available because we have this reproducible way of doing a capsulotomy and taking the cataract out. It’s the potential for further innovation that excites me more than anything else,” Dr. Daya said. EWAP Editors’ note: Dr. Daya has financial interests with Bausch + Lomb. Dr. Foster has financial interests with AcuFocus (Irvine, Calif., USA) and Alcon. Dr. Packer has financial interests with LensAR and Bausch + Lomb. Dr. Talamo has financial interests with OptiMedica. Cont act info rmation Daya: +44 0800 011 2882, sdaya@ centreforsight.com Foster: 970-221-2222, gjlfos@aol.com Packer: 541 687 2110, mpacker@finemd.com Talamo: 781-890-4979, jtalamo@lasikofboston.com On the edge - from page 8 LRI with a standard monofocal,” said Dr. Foster, who has used the LenSx model for over a year in commercial use. “I have a strong preference for the femtosecond laser over diamond bladed LRIs because it reduces so many of the possible variables that lead to inconsistent outcomes,” he said. He usually employs the laser for astigmatism within the 1-D range—for patients with higher astigmatism, he will combine the LenSx with a toric IOL. When using the toric to correct higher degrees of astigmatism, he’ll still create some of the femtosecond arcuate incisions available but not open them, just as other surgeons have described for other laser models. “I use the slit lamp later to titrate the results. At the slit lamp, I use a Sinskey hook and open up incisions a bit to get more refractive effect and fine-tune the patients’ results,” he said. Dr. Foster believes use of this technology will improve as surgeons become more accurate with their alignment and marking to reduce parallax. He also thinks that the nomograms under evolution for use with the laser will help surgeons who are new to the technology. Some nomograms formed from collective wisdom are available on internet discussion lists, Dr. Foster said . EWAP Editors’ note: The physicians have financial interests with the laser manufacturers that they discuss in this article. Contact information Culbertson: 305-326-6364, wculbertson@med.miami.edu Foster: 970-221-2222, gjlfos@aol.com Packer: 541-687-2110, mpacker@finemd.com Talamo: 781-890-4979, jht1@comcast.net