EyeWorld Asia-Pacific September 2015 Issue

Femto cataract clinical update September 2015 37 EWAP SECONDARY FEATURE believe the technology yields better results,” Dr. Yeoh said. In Ireland, however, the femtosecond laser is not yet being used for cataract surgery. Dr. Cummings attributed this to insurance companies because currently the laser is not a covered procedure and copayments are not permitted. Although he is using the femtosecond laser for other procedures, like femtosecond LASIK and for intrastromal pockets and some corneal rings, the lack of insurance coverage and the ability to copay are the real obstacles in the adoption of femtosecond laser- assisted cataract surgery in Ireland, he said. Specific challenges in different countries Dr. Yeoh said that the biggest challenge is the cost of purchase and the “click” fee, which he said makes the surgery 25% more expensive than standard phaco. Dr. Lawless said he sees no specific challenges with the femtosecond laser. “Really the only challenge is ready access to the technology and having the technology in place in a hospital or day surgery center that you routinely operate,” he said. “There are no installations in major teaching hospitals so ophthalmology trainees [registrars] do not gain practicable experience through their training program, and I think this is a shame but is a pattern that is mirrored around the world.” Reimbursement of FLACS In Australia, there is no reimbursement for the laser portion of femtosecond surgery, Dr. Lawless said. “There has been a pattern of copayment for many years so that if a patient wishes to have cataract surgery performed privately, part of the surgical fee comes from the federal government system [Medicare] and part of it is paid by the patient’s health insurance, and the patient tops up the rest,” he said. Because patients have been used to a copayment system, when they go privately for surgery, the LenSx (Alcon, Fort Worth, Texas) is one more copayment, so it is not an unfamiliar setting for patients, he said. In Singapore, Dr. Yeoh said, patients pay for the use of the femtosecond laser on their own, and he added that those who are insured will usually be reimbursed by their healthcare providers. Advantages and disadvantages Dr. Cummings said that the literature on femto is not yet showing that it’s better than phaco. Patients like the idea that femto can make a repeatable capsulorhexis every time, he said, but they really care about how they will see compared to someone who had regular phaco. “The benefits don’t currently justify getting the device when it means the patient is going to pay for the entire procedure rather than just for the copay,” he said. “But there’s no question that in time it will be the way it’s done.” He believes that it will make sense to use the femtosecond laser when there are lenses specifically made for femto and for a perfect rhexis. The femtosecond laser gives better positioning of the capsulorhexis and softens the lens, he said. “I personally think it will take off when lenses come onto the market that have been designed specifically for femto phaco.” The advantages of the femtosecond laser are well documented, Dr. Yeoh said, including rounder and more precise capsulorhexes, lower ultrasound energy usage, and more consistent incisions. “These, however, have not translated to more precise refractive outcomes,” he said. “Most surgeons agree that while the jury is still out on the refractive benefits of FLACS for ‘standard cataracts,’ the advantages in complex cataracts like dense nuclei, subluxated lenses, fibrotic cataracts, and posterior polar cataracts are obvious.” Apart from the cost of the procedure, the only other issues that may be faced are the greater length of time for surgery and greater space requirement, Dr. Yeoh said. New surgeons will also need to modify their surgical technique. “It’s my firm belief that if cost was not an issue, many surgeons would take up FLACS,” he said. Dr. Lawless thinks that the major advantage of FLACS is that it is safer. “The capsulotomies with current technology and techniques are round, centered, and robust,” he said. “My anterior capsular tear rate compares favorably to manual surgery, and I have published on this.” Additionally, the nuclear fragmentation means the time inside the eye with phacoemulsification is less, and less energy is used with less manipulation. Corneal incisions are the least useful part of the technology, Dr. Lawless said, but he performs them routinely, occasionally opening them with a blade. “The safety that is conferred by the capsulotomy and lens fragmentation is obvious to a surgeon who uses this technology frequently,” he said. “The only disadvantage is cost to the patient.” Changing technique Dr. Lawless said that the femtosecond laser has changed his phaco technique. “I was always a prechopper in the Akahoshi mode prior to femtosecond surgery, and I still prechop, but these days with a blunt prechopper,” he said. “I am a person who likes a stable anterior chamber, so I am lucky that I have the Centurion system [Alcon] to allow me to achieve this.” Dr. Lawless added that he has slightly modified his cortical aspiration to remove the cortex in a more peripheral fashion. He finds this to be quick and efficient. “Overall, the femtosecond laser has led to less intraocular trauma and quieter, more comfortable eyes,” he said. “I no longer use the astigmatic incisions with the femto laser, preferring instead to use toric IOLs down to low levels of astigmatism as they are more predictable than even a laser incision can be.” Dr. Yeoh uses the femto prechopper to complete nucleus separation in most cases of femto- fragmented nuclei. “Since getting comfortable with using the femto prechopper, I am now using a regular prechopper for nuclear division in many of my routine non-FLACS softer cataracts,” he said. Additionally, a greater appreciation of a round and well- positioned femto CCC has led him to try harder to achieve the same with the manual CCC technique. EWAP Editors’ note: Dr. Cummings has financial interests with Alcon. Dr. Yeoh has financial interests with Alcon (Fort Worth, Texas) and AMO (Abbott Park, Ill.). Dr. Lawless has no financial interests related to the article. Contact information Cummings : abc@wellingtoneyeclinic.com Lawless : Michael.lawless@visioneyeinstitute.com.au Yeoh : ersryeoh@gmail.com