EyeWorld Asia-Pacific June 2014 Issue

10 June 2014 EWAP FEAturE Femtosecond - from page 9 With a laser capsulotomy, surgeons must go under the capsule and grab the cortex with the I/A tip during cortical cleanup. However, Dr. Talamo has found cortical cleanup easier than with traditional cataract surgery. “The laser leaves a predictable thickness in terms of the thin layer of cortex that’s left behind. I use 500 μm of untreated tissue between the posterior capsule and at the back of the laser treatment. You typically don’t have much of an epi- nucleus,” he said. Dr. Talamo does find some strands of tissue occasionally but said that it’s important to feel comfortable going under the capsule to get the cortex. He prefers to use bimanual irrigation and aspiration to get the cortex. Dr. Weinstock said one surgical aspect he continues to do manually is wound creation. “If there’s one part of the femto technology that’s not fully mature, it’s wound creation. Trying to get that perfect limbal position and open it easily just hasn’t happened in my experience,” he said. “In my hands, the diamond blade is more efficient and precise.” There’s also some change to surgical flow that patients may not notice but surgeons will, Dr. Slade said. “It’s fairly disruptive in that the patient goes from preop to the laser area and then the OR. For the surgeon, it’s another sit down. It’s also more chair time with the patient, which isn’t necessarily bad. Using the laser takes the same amount of time as surgery, from 3 to 5 minutes at the laser to 3 to 5 minutes in surgery,” he said. Accuracy and safety The femtosecond lasers are said to enhance accuracy and safety of the cataract procedure. When it comes to safety, surgeons must consider that term in both the clinical and regulatory senses, said Dr. Slade. Although the regulatory definition of safety involves studies with thousands of patients, the surgeons quoted here shared their personal observations and experiences. “My impression is that it does add accuracy, precision, and in some cases, does have unique safety aspects,” Dr. Slade said. Those aspects include providing a more seamless surgery for patients with a white cataract, compromised zonules, or pseudoexfoliation. “Clinically, we see that the corneas are clearer and that there’s a tighter spread of our spherical outcomes. We also have a better result with the laser arcuates than the manual arcuates that we did before,” Dr. Slade said. Dr. Weinstock concurred with Dr. Slade’s accuracy-related observations. “The optical zone is more precise, and the depth is more exact than anything I can do with a diamond blade,” he said. Because there is less nucleus manipulation and reduced phaco time and energy, Dr. Weinstock has found use of the laser helpful in patients with unhealthy corneas, including those with Fuchs’ dystrophy. Dr. Lawless also feels confident using the laser in mild cases of Fuchs’ dystrophy as well as with white cataracts. “The other time I find it of particular use is in potential floppy iris syndrome where the incisions, capsulotomy, and nucleus divisions are performed before the eye is open,” he said. “I still use intracameral adrenaline in these cases, but I have found that the laser approach makes these cases more routine.” Analysis from Dr. Talamo’s center has found that instead of reaching within a half diopter of the intended refractive goal in 70% of patients, his most recent results using the laser achieved that goal for 88% of patients. He believes that number will continue to increase. Surgical recovery also appears more seamless, said Dr. Trattler, who uses the LENSAR laser. “My patients see better at day one because there’s less phaco energy used. There’s faster visual recovery and less corneal edema,” he said. Dr. Lawless said his anterior capsule tear rate with the laser is 0.1%, and the best he could ever achieve with manual surgery was 1%. He also finds that the use of intrastromal astigmatic incisions combined with on-axis surgery where indicated have helped him tighten his astigmatic results, especially in multifocal IOL patients with preexisting corneal astigmatism of 1.1 D or less. Patient reaction Aside from the higher price tag associated with use of the laser, patients have reacted favorably to femto-assisted phaco, these physicians reported. “We present both options as viable ways of doing surgery. Without exception, patients wanting refractive cataract surgery want the laser procedure,” Dr. Talamo said. Not infrequently, patients going the non-premium IOL route elect for the laser as a strategy for astigmatism correction as well. “Patients know about it, and they want it. They’ve heard about it from friends and family who have had the procedure,” Dr. Trattler said.” EWAP Editors’ note: Drs. Lawless and Slade have financial interests with Alcon. Dr. Talamo has financial interests with OptiMedica/Abbott Medical Optics. Dr. Trattler has financial interests with LENSAR, Abbott Medical Optics, and Bausch + Lomb. Dr. Weinstock has financial interests with Bausch + Lomb. Contact information Lawless: Michael.lawless@visioneyeinstitute.com.au Slade: sgs@visiontexas.com Talamo: jtalamo@lasikofboston.com Trattler: wtrattler@gmail.com Weinstock: rjweinstock@yahoo.com