EyeWorld Asia-Pacific December 2012 Issue

8 December 2012 EWAP FEATURE 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 excellent 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 capsulorhexis can be centered on the pupil, on the capsular bag, or relative 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 system of the LensAR (Orlando, Fla., USA) is what set it apart from the other systems, and as a result, “the ability to address dense cataracts is astonishing.” When he used the laser to treat dense cataracts in Peru, the laser “cut really deeply, close to the posterior capsule. The LensAR can break through that dense posterior plate other systems using optical coherence 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 fragmentation, 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 happening with cataract femtos.” Dr. Packer added his first surgery with the femto took less than 2 minutes 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 traditional 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 learning curve, but allowances need to be made for learning the new techniques. A refractive surgeon who is comfortable with femtosecond technology will find the transition to femtosecond cataract surgery relatively 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. His first impression of the technology “was that it was more of a struggle than regular cataract surgery,” and hydrodissection caused some issues. He’s since developed a new hydrodissection technique that’s “completely unique for femto-phaco.” He also advised those new to the technology to schedule fewer cases and take the time to learn the laser’s nuances. Since April, not one of his femto-phaco patients has developed cystoid macular edema, Dr. Daya said. “It may be the laser itself, it may be because we’re not in the eye as long,” he added. TRICKS FOR AVOIDING INTRAOPERATIVE INGROWTH Kasu Prasad REDDY, MD Chairman, Maxivision Eye Care Centres 6-3-9-3/A/1/1 Somajiguda, Hyderabad 500082, India Tel. no. +91-98480-46919 Fax no. +91-40-23414041 kasuprasadreddy@gmail.com I n my case, destiny dictated in October 2010 and I conducted the first study for the Victus of Technolas, Munich, Germany. The capsulotomy study, with IEC and IRB approvals in India, comparing manual vs. femto proved that the centration, circularity and the diameter are 100% accurate in comparison with the manual eyes with absolute precision and safety and repeatability as Dr. Daya mentioned. For me, the very first femtocapsulotomies on intumescent and subluxated pediatric capsular bags were the most exciting surgical steps that ever happened in my hands. I knew immediately that we had a winner in our hands and the technology is here to stay and progress into the future for better, irrespective of the cost, that may eventually go down. Being there first, I contributed to many small changes and noticed that the Victus has many safety features, the OCT is excellent, the curved interface creates smooth applanation with a lower rise in IOP, the docking is very surgeon-friendly, the IPS (Intelligent Pressure System) in docking saves you from corneal folds and having completed over 1,100 eyes with no brakes in service gave me lot of comfort. I now have two machines with one more on order. I agree with Dr. Foster on his comment on surgeon evaluation of various machines and I can only speak about the Victus. Femto fragmentation, with Indian hard cataracts, where I kept the ablation 1,000 microns away from the posterior capsule has helped me with safety and I have never had a nuclear drop in the over 1,100 eyes that I have performed; no retinal issues, no endothelial cell loss more than the routine. In recent months, I have found the attached microscope very useful and have conducted 14 pediatric cases, some traumatic, under the same machine in the same room, proving the option of operating in the same room or in the main OR, with the Victus. I also docked on an eye after the incisions and conducted femtophaco and traveled immediately, with the patient, in an aircraft to a different city and conducted live surgery, while checking all the parameters, with absolute safety. Dr. Stodulkar has already conducted the first posterior capsulotomy and I am sure more and more eminent eye surgeons will do more wonders with femtophaco laser systems. The Victus can also be used for additional applications like the flaps, IntraCOR presbyopic correction, tunnels, kerotoplasties, and is yet to perform femto incisions. The downside to femtophaco of SCH, incomplete capsulotomy, miosed pupil, and the learning curve with Docking and I&A are all manageable and I am sure will be improved. Editors’ note: Dr. Reddy is a consultant for Technolas Perfect Vision, but has no financial interests related to his comments. Views from Asia-Pacific continued on page 11 On the edge - from page 7