EyeWorld Asia-Pacific June 2014 Issue

June 2014 9 EWAP FEAturE continued on page 10 Views from Asia-Pacific Ronald YEOH, MD Senior Consultant, Singapore National Eye Centre 11 Third Hospital Avenue, Singapore 168751 Consultant Eye Surgeon & Medical Director, Eye & Retina Surgeons #13-03 Camden Medical Centre, 1 Orchard Boulevard, Singapore 248649 Tel. no. +65-67382000 Fax no. +65-67382111 snecyls@snec.com.sg F emtosecond laser-assisted cataract surgery (FLACS) is the hottest topic in cataract surgery today. While the momentum is shifting inexorably toward FLACS, there are still issues. Naysayers quote the lack of data showing improved refractive precision with FLACS and indeed postulate that FLACS may not be as safe as phaco. It is indeed hard to prove the superiority of a new procedure over an established procedure which is already very good. This is the challenge facing FLACS today. If we look back at how long it took for definitive data to prove the superiority of phaco over planned ECCE we can also postulate that it will take time for FLACS to show this superiority. Prior to this evidence becoming available though, many eye surgeons had already converted to phaco because intuitively we knew that phaco was better than ECCE. While we as phaco surgeons may be very good at doing our manual capsulorhexes (CCC), we may not be good 100 times out of 100. FLACS allows us to do more consistently sized and positioned CCCs. Again, we have to wait for refractive results to validate this point. What is perhaps less appreciated is the fact that a FLACS procedure will make cataract surgery easier for the younger surgeon and possibly extend the surgical life of older surgeons. As the data is being gathered for refractive precision, it is imperative that the FLACS procedure be at least as safe if not safer than phaco. In the early days of FLACS, the incidence of capsular tags, bridges and radial tears was clearly unacceptable and would have sounded the death knell of FLACS had things not improved. It is also understandable that while new technology and surgical techniques are evolving, there is a learning curve and a higher complication rate. As long as one is careful with handling the now uncommon FLACS-related capsular tags, bridges or anterior capsule tears, then major complications such as posterior capsule ruptures or dropped nuclei should not occur. Fortunately, technology and updates have made the completeness of the femto CCC the norm and I believe that a FLACS procedure is as safe as phaco today. Where FLACS has an advantage over phaco is in handling the more complex cataracts such as subluxated cataracts, fibrous capsules, polar cataracts, and dense cataracts. Finally, we always need to be cost effective in our choice of technology and the onus is on industry to bring the price of this innovative technology down to the level where the cost is not the limiting factor to widespread acceptance. Editors’ note: Dr. Yeoh is on Alcon & AMO speaker panels. the surgery,” said Dr. Slade, who uses the LenSx laser. “It makes the incision, does the capsulorhexis, and fragments the nucleus. It also does arcuate incisions that we would have done by hand.” “Having the cataract fragmented by the laser reduces the need to crack and chop,” Dr. Weinstock said. “This reduces mechanical stress on the zonules. We don’t need to manipulate the nucleus as much. That helps to reduce phaco time and energy, leading to less mechanical stress on the capsule.” Michael Lawless, MD , Vision Eye Institute, Chatswood, New South Wales, Australia, who uses the LenSx laser, said the laser ensures consistent incisions, a guaranteed capsulotomy size, and he is able to place the capsulotomy in the center of the entrance pupil with more certainty. Additionally, the surgeons interviewed will use the laser for arcuate incisions relative to astigmatism as necessary. Pearls for managing challenges However, for laser use to be effective, Dr. Weinstock finds that patients need to be well dilated before surgery. Patients sometimes need extra dilating drops after the laser because the laser treatment can cause miosis. When there are rare cases that an eye will not dilate, Jonathan H. Talamo, MD , associate clinical professor of ophthalmology, Harvard Medical School, and medical director, Surgisite Boston, Mass., U.S., who works with the Catalys laser system (OptiMedica/Abbott Medical Optics, Santa Ana, Calif., U.S.), will use an ophthalmic viscosurgical device and insert a Malyugin ring (this is an off-label use of the laser system). “Because the docking is so gentle, we can close up the incisions and redock the eye,” he said. He finds he can treat a patient successfully if they dilate beyond 6 mm, but surgeons new to femto-cataract laser use should aim for at least 7 mm of dilation, he recommended. The laser also requires some patient selection considerations— specifically, surgeons will want patients who can fixate for a length of time, said Dr. Talamo. “It has to be someone who can lie still while you do a docking procedure and image them,” he said. “If you give too much IV sedation, patients can get too drowsy and uncooperative, and that can cause problems with suction. It’s a delicate balance with anesthesia,” Dr. Weinstock said. Another challenge with the laser that Dr. Weinstock has found is with cortical cleanup. “When the laser creates the capsulotomy, it also cuts the cortex. This often creates a challenge in hydrodissection and finding the tissue plane that’s so easy to find with a manual capsulorhexis between the cortex and the underside of the anterior capsule.”