EyeWorld Asia-Pacific September 2015 Issue

30 Femto cataract clinical update September 2015 EWAP SECONDARY FEATURE Views from Asia-Paci c Pannet PANGPUTHIPONG, MD Deputy Director General Department of Medical Services, Ministry of Public Health Nonthaburi Province, Thailand pannetp@hotmail.com The Amazing Technology That May Have Come Too Soon – FLAC W hen I was a resident, we were in transition from ICCE to ECCE with IOL implantation. I had witnessed a big improvement in the surgical outcome that greatly enhanced the patient’s quality of life. After becoming an ophthalmologist, I was among the few pioneering surgeons in Thailand who performed phacoemulsi cation and developed surgical techniques to deal with dif cult cataracts such as those with a hard nucleus, loose zonules, or small pupils commonly found in the Asia-Paci c region. Transition to phacoemulsi cation with proper surgical techniques and foldable IOL technologies including premium IOLs resulted in signi cant improvement in visual outcome. The bene ts of small incision and rapid visual recovery allowed phacoemulsi cation to gain popularity rapidly. Looking at the health economics aspect of cataract surgeries, we may apply the Pareto Principle or the 80-20 Rule (Figure 1) to understand the cost–bene t or the input– output correlation of different technologies. With ECCE, we may assume that 20% of input (cost/expense) results in 80% of the perfect outcome. With phacoemulsi cation, we spend another 30% (total of 50%) of input to gain an additional 15% (total of 95%) of the perfect outcome. With FLAC, we spend another 45% (total of 95%) of input to gain only a few percent better results. Gaining the last 1% of the ideal outcome may consume even more. But these gures will depend on surgeons’ experiences. Cost that increases to almost double with FLAC when compared to phaco will show very little improvement in the hands of an experienced surgeon. However, for a novice surgeon, the bene ts or improvement may be greater. We have adopted FLAC since 2012, the most important reasons being to learn about the new technology and to assess its value. It seems to me that this is an amazing technology, but it may come to us too early with too high a cost at the moment. Editors’ note: Dr. Pannet has no nancial interests related to his comments. YAO Ke, MD Professor Eye Institute of Zhejiang University Eye Center, Second Af liated Hospital of Zhejiang University, College of Medicine 88 Jiefang Road, Hangzhou, 310009, China Tel. no. +86-571-87783897 Fax no. +86-571-87783897 xlren@zju.edu.cn I read with great interest the article “Forgoing the femtosecond laser”. The opinion raised by the global experts is worth contemplating. As a phaco pioneer in China, I have performed more than 30,000 surgeries in the last 25 years. I was not in a hurry to jump into FLACS when it was rst brought to the Chinese market in 2013 because I thought the same way as the doctors in the article. My original viewpoint underwent a change after the rst 100 cases and I have since become the one of the doctors doing the most FLACS in China today. A complete 360-degree and well-centered laser capsulotomy can be achieved in almost every case. Highly skilled surgeons can achieve complete and well-centered capsulotomies manually but in most cases not with the same precision. Femtosecond lasers with integrated image-guided software have demonstrated increased precision and safety in the creation of perfect capsulorhexes, which makes the procedure more controlled and reproducible, resulting in better optimized refractive outcomes. A recent meta study has reported better visual outcomes and reduced phaco energy and EPT through FLACS. 1 In China, no billing for FLACS is permitted and patients are required to pay privately for the additional expense. Therefore, a signi cant number of the wealthy population with a lifestyle-enhancing refractive goal may opt and pay extra for it. Nonetheless, our primary goal as clinicians is to achieve better outcomes instead of accounting for nancial issues rst. In 2014, more than 1.5 million cataract surgeries were performed in China, with over 13,000 performed by FLACS. In our eye center, we performed 1,000 cases of FLACS and 10,000 of phaco last year. I agree that many issues regarding practical use have to be addressed. However, I remain convinced that the technology was designed to improve safety and ef cacy and should be incorporated into our practices in the same way that phacoemulsi cation supplanted ECCE in the treatment of cataracts. Additionally, the costs could decrease with more entrants into the market. It will be more nancially ef cient with widespread adoption which in turn, will lead to its development. It should also be emphasized that FLACS may help a group of less-experienced and skilled surgeons. It is therefore valuable to make an ongoing effort to guide the way forward in this new approach to performing cataract surgery. Reference 1. Chen X, Xiao W, Ye S, et al. Ef cacy and safety of femtosecond laser-assisted cataract surgery versus conventional phacoemulsi cation for cataract: a meta-analysis of randomized controlled trials. Sci Rep . 2015 Aug 13;5:13123. Editors’ note: Prof. Yao has no nancial interests related to his comments. Figure 1. The Pareto Principle Source (all): Pannet Pangputhipong, MD Forgoing the femtosecond - from page 29 continued on page 32