EyeWorld Asia-Pacific September 2014 Issue

40 EWAP CATARACT/IOL September 2014 Views from Asia-Pacific Robert Edward ANG, MD Senior Consultant, Asian Eye Institute 8th Floor Phinma Plaza Rockwell Center, Makati City, Philip- pines Tel. no. +63-2-898-2020 Fax no. +63-2-898-2002 angbobby@hotmail.com I ncorporating a femtosecond laser into a cataract practice is a huge decision. For those who purchased the laser early on, we did so because we saw the potential advantages; however, we also knew its superiority over current phacoemulsification outcomes has not been established and the technology will continue to evolve. For a successful adoption of this new technology in any practice, there are three important stakeholders who must be satisfied. For patients, safety and outcomes are their important concerns. Undoubtedly, femtosecond technology has made capsulotomy, lens fragmentation, and corneal incisions more repeatable. For the experienced surgeon, these steps may be easy, but for the less experienced surgeon, or in difficult scenarios such as unstable zonules, dense cataracts or shallow anterior chamber, having the femtosecond laser can help avoid complications. In addition, less phaco time means less loss of endotheial cells. Increasing the chance of a complication-free procedure may already be enough justification for most patients. However, objectively proving better refractive and visual outcomes is more difficult because of the good results we are already achieving with conventional phacoemulsification. For the surgeon like myself, the biggest impact is the laser gives me a round, centered, predictably-sized capsule opening all the time regardless of the consistency of the capsule, cataract density, and zonule condition. Lens fragmentation lessens my phaco time and helps me chop dense cataracts easier. The corneal incision allows me to offer patients a blade-free procedure but a blade can also perform this step easily. For the institution, economics play a big part in the discussion. It is a huge marketing advantage to be able to promote laser cataract surgery or bladeless cataract surgery. But paying for the equipment, maintenance, and consumables is a huge burden that unfortunately has to be passed on to the patients. We decided on a Victus femtosecond laser because it can do all the cataract steps, plus LASIK flaps, channels for intracorneal rings and corneal transplants. Having multiple anterior segment functions allows us increased utilization and better return on investment. In conclusion, current knowledge suggests the femtosecond laser improves safety and predictability of the cataract procedure. It has the potential to follow femtoLASIK whereby the main reason for widespread adoption was not superior outcomes compared to blade LASIK but the increased confidence in the procedure because of fewer flap complications and consistent flap thickness contributing to improved safety. Editors’ note: Dr. Ang is a consultant for Bausch + Lomb but has no financial interests related to his comments. Pannet PANGPUTHIPONG, MD Director, Mettapracharak Hospital and Eye Institute, Department of Medical Services, Ministry of Public Health 52 Moo 2, Tambon Raiking, Ampur Sampran, Nakornpathom Province, Thailand 73210 Tel. no. +6634-225417 Fax no. +6634-321243 pannetp@hotmail.com I have incorporated femto laser into my practice for almost 2 years now and found that the laser can make a well-centered capsulorhexis, effective nuclear fragmentation, and precise corneal incisions. These improvements may lead to a better refractive outcome and enhance patient safety. However, the level of benefit may vary from patient to patient or from surgeon to surgeon. Patients who will receive toric or multifocal IOL as well as patients with complicated cataract like hard nucleus or loose zonules may derive greater benefit from the femto laser. In the hands of experienced surgeons, the outcomes of manual performance may already be close to those from femto laser. Experienced surgeons may find that, for a minimal improvement, they must spend extra time to set up the laser. On the other hand, novices may find the femto laser making their life easier and requiring less total surgical time. Therefore, femto laser technology may narrow the gap between expert and novice. If most beginner surgeons become overly reliant on the femto laser, then there will be a legitimate concern involving the loss of essential surgical skills to deal with difficult or emergency situations. In the future, there may be fewer competent surgeons available for difficult cases such as cloudy corneas, hyper mature cataracts, or hard nuclei with loose zonule. We must be careful not to become too machine dependent. As I work in the public sector and am often involve in policy making, cost-benefit optimization is an important consideration. The Pareto’s Principle or the 80–20 Rule tells us that the first 20% of input or effort provides 80% of output or results (Figure 1). Achieving the remaining 20% of result will need at least another 80% of effort. Current standard cataract surgery, phaco with monofocal foldable lens, already captures about 90% of the ideal outcome. As we struggle for the best outcome, the last few percentage of improvement will consume extraordinary resources. Femto laser and special IOLs (toric, multifocal, and accommodative IOL) attempt to capture the last 10% and may double or triple the cost of the surgery. Limited resources in a developing country stipulate that we can only hope to provide very good care for most people, not the best service for everybody. But if there is enough evidence to prove the benefits of femto laser in complicated cataract, policymakers may include femto in the reimbursement for high-risk groups. Otherwise, patients have to pay out of their own pocket. Premium IOL patients may choose femto to enhance the outcome and pay the extra cost. Though the femtosecond laser provides a better outcome, we are waiting for the cost to come down. Editors’ note: Dr. Pangputhipong has no financial interests related to his comments.