EyeWorld Asia-Pacific June 2016 Issue

June 2016 10 EWAP FEATURE was significantly more accurate in terms of creating a reproducible capsulotomy compared to manual capsulorhexes. 5 Stephen McLeod, MD , chair, Department of Ophthalmology, UCSF, pointed out that the current FDA-approved femtosecond laser platforms for use in cataract surgery are still in their first Views from Asia-Paci c Johan A. HUTAURUK, MD Director, Jakarta Eye Center Jl. Cik Ditiro 46, Menteng, Jakarta 10310, Indonesian Tel. no. +62-21-2922-1000 Fax no. +62-21-2569-6099 johan.hutauruk@jec.co.id T here are numerous studies reporting the comparison of femtosecond laser-assisted cataract surgery (FLACS) and standard phacoemulsi cation with no signi cant difference regarding the visual outcomes. Since the results of both procedures are comparable, surgeons then discuss the advantages or disadvantages of FLACS in their daily practice. FLACS in daily practice • Corneal incision: Making clear corneal incision or secondary incision is not too complicated and is straightforward with the slit knife, so in my hands using FLACS to make incision is not important and time consuming. • Capsulorhexis: There is no doubt the size and shape of capsulorhexis using FLACS is more predictable and we can get perfect capsulorhexis in almost all cases; this is the most prominent advantage of FLACS compared to manual phacoemulsi cation. A patient with small pupil on the other hand will be better off without FLACS since it is almost impossible to create capsulorhexis without surgical intervention using viscoelastic or pupil expansion rings. • Nucleus management: Several studies have shown that FLACS reduced the total ultrasound energy which might be beneficial for patients with dense cataract and/or low preoperative endothelial cell values. • Managing corneal astigmatism: Treatment of preexisting astigmatism during cataract surgery with FLACS offers a greater degree of precision and accuracy than manual methods. • Patient flow: Moving the patient after FLACS to another table for phacoemulsification is not comfortable either for patients or for surgeons; this 2-stage procedure prolongs the time of surgery between 5 to 20 minutes. • Cost: This is the major disadvantage of FLACS, if we consider the expenses to invest for the laser, maintenance, and pay per click. Based on my observations above and considering the comparable outcomes between FLACS and standard phacoemulsi cation, FLACS is a “nice to have” technology but cannot replace conventional phacoemulsifcation. This might be because standard phacoemulsifcation has evolved for more than 50 years while FLACS is still in its infancy. This is not the case with the femtosecond flapmaker in LASIK which is significantly better and safer for creating thinner flaps and totally can replace microkeratome. FLACS training for residents Cataract surgery using FLACS is a 2-stage procedure that requires skill and experience in order to manage incomplete capsulorhexes with FLACS and to avoid complications in nucleus management, not to mention the very high expectations of patients with FLACS due to the higher cost. It is more appropriate and useful to train residents with standard phacoemulsi cation while waiting for the FLACS technology to get better. My hope in the future is that FLACS will be more affordable and portable, with a small removable handle to perform laser cataract surgery so there will be no need to move the patient to another room to perform phacoemulsi cation. Editors’ note: Dr. Hutauruk declared no relevant financial interests. iteration, however sophisticated they might be. Given that femto can at least compete with the high standards of manual modern phacoemulsification is impressive, he said, but the technology is still in its infancy. “It does say a great deal, however, that a radically different approach to some of the key elements of a procedure where the current standard has evolved over decades of refinement and sequential improvements in instrumentation and techniques can compete at such an early stage,” Dr. McLeod said. The “big picture opportunities for improvement” for FLACS, Dr. McLeod added, include cost, speed, and efficiency, but he noted what he thinks are some clear benefits of using the laser at least for some specific parts of the procedure. In terms of reproducibility and predictability of the size and centration of the capsulorhexis, the femtosecond laser seems to win out over manual capsulorhexis creation, he said, adding that he has been “extremely impressed” with the capsulorhexis edge in the months following surgery, preventing uneven capsular contraction. It’s the laser’s consistency of the edge of the capsulorhexis that could pose a problem. Dr. McLeod explained its potential to skip areas and create tags, saying this “intrinsic postage stamp quality” could increase the risk for anterior capsule tear. Dr. McLeod said conventional phaco surgery still outperforms femto when it comes to cost, efficiency, overall energy delivery to the eye, greater capsulorhexis integrity, and easier cortical clean up. Conventional methods are also preferred in patients with small pupils. Dr. McLeod further explained his stance on the energy delivery of the two methods. “The now established conventional wisdom is that with the femtosecond laser, you are able to reduce energy delivery to the eye,” he said. “However, that is specific to the reduced phaco energy. The total energy delivered to the eye actually comprises both femtosecond laser energy and phaco energy. We have to account for additional femtosecond energy that has been delivered to the eye for the capsulorhexis that in standard phaco is achieved mechanically, as well as the femtosecond energy that has been delivered for the lens cleavage.” Femto in cataract - from page 9