EyeWorld Asia-Pacific September 2014 Issue

43 EWAP CAtArACt/IOL September 2014 Views from Asia-Pacific Mahipal SACHDEV, MD Chairman and Medical Director, Centre for Sight Group of Eye Hospitals B-5/24 Safdarjung Enclave, New Delhi -110029 Tel. no. +91-9810046017 Fax no. +011-41651744 drmahipal@gmail.com “ W hether femto cataract technology will live up to the hype” seems to be the hottest debate among ophthalmologists today. Though the jury seems to be divided, most surgeons who have used the femtosecond laser see the definite benefits of this technology. My 2 years and 1,000 cases with the LenSx platform make me firmly believe that this technology allows for a safer and easier cataract removal with precise refractive outcomes. The initial reports comparing the evolved technique of phacoemulsification in mastered surgical hands with the nascent technology of femto-cataract with “learner surgeons” was at best unfair. As surgeons gain experience and as this technology evolves, there is no doubt that the femto procedure will rightfully claim its position as the gold standard for cataract removal. With recent software upgrades, the technology is now giving near perfect outcomes in my hands. I also see the learning curve getting shorter, as many of my associates have moved onto this technology with increasing ease. The rhexis is now a dream—normally found free floating with no problems of capsular tags or discontinuous treatment. The perfect rhexis size and location allows near perfect IOL placement helping us attain near emmetropic results. The other feature that adds a huge benefit is the correction of coexisting astigmatism. With the arcuate incision option of the femto-cataract laser, my LRI frequency is up to 40%, which means I am tackling lower degrees of astigmatism more frequently and giving a better refractive outcome to most of my patients. Also, my premium IOL usage has gone up with greater use of multifocal and toric IOLs. I am more confident of the visual outcome and can almost always assure my patients of improved results with femto-laser cataract surgery. With the matrix pattern of nuclear fragmentation, the phaco energy is further minimized giving pristine clear corneas the next day. The advantages of enhanced safety and precision resonate well with patients who are increasingly willing to “upgrade”. Perhaps the only downside I see right now is the cost factor. As this platform develops into an “all-in-one” cataract and refractive technology, more and more surgeons may find it a cost-effective investment. An increasing market and the availability of multiple platforms will see a competitive reduction of the cost per procedure. As more and more surgeons and patients begin to experience this technology, the debate may finally be answered with an affirmative nod in favor of the femtosecond laser—the technology which seems poised to define the future of ophthalmology. Editors’ note: Dr. Sachdev is a consultant for Alcon, Abbott Medical Optics, Bausch + Lomb, and Allergan, but has no financial interests related to his comments. Hiroko BISSEN-MIYAJIMA, MD, PhD Professor & Chair of Department of Ophthalmology, Tokyo Dental College Suidobashi Hospital 2-9-18 Misaki-cho, Chiyoda-ku, Tokyo 101-0061 Japan Tel. no. +81-3-5275-1912 Fax no. +81-3-5275-1912 bissen@tdc.ac.jp M ost ophthalmologists who started femtosecond laser-assisted cataract surgery agree that this would become the standard technique of cataract surgery in the near future based on their own experiences. However, if they were asked to answer the question like the title of this article, “can the femto for cataract live up to its hype?” their answer becomes conservative. We wonder why they can’t clearly answer “yes” if the laser application based on the results of optical coherence tomography has a great potential to improve surgical outcomes. Anterior capsulotomy is a good example. The size and position of the capsulotomy is stable and reproducible, which allows for the ideal positioning of the implanted intraocular lens, resulting in better visual acuity. Moreover, this will be helpful in developing new intraocular lenses. The structure of the corneal incision is unique and is expected to show better sealing and less surgically-induced astigmatism. Astigmatic correction with intrastromal incision is only possible with the laser procedure. Laser fragmentation of the lens will reduce the time of ultrasound in phacoemulsification. The grid pattern of laser application allows the lens aspiration without ultrasound in most cases. Are these advantages very attractive to most cataract surgeons? I think so, but they should justify the purchase of the very expensive laser itself, maintenance, running costs, and so on. Most countries are facing the problem of medical care, especially in this aging era. It is essential to ensure both medical and economical advantages. Even if we do not consider the cost, the indication of femtosecond laser-assisted cataract surgery is another important reason for the penetration to cataract surgery. The eye with a small pupil, corneal opacity, or corneal scar from previous surgery is not indicated. Small palpebral eyes require lateral canthotomy. I believe these problems would be solved in the near future, most probably earlier than we imagine. Then, we can definitely answer “yes” to this question. Editors’ note: Prof. Bissen-Miyajima has no financial interests related to her comments.