EyeWorld Asia-Pacific June 2016 Issue

June 2016 EWAP FEATURE 11 Views from Asia-Paci c Ronald YEOH, FRCS, FRCOphth, DO, FAMS Adj Ass Professor, Duke-NUS Grad Med School and Singapore National Eye Centre Consultant Eye Surgeon & Medical Director, Eye & Retina Surgeons #13-03 Camden Medical Centre, One Orchard Boulevard, Singapore 248649 Tel. no. +65-67382000 Fax no. +65-67382111 ersyeoh@gmail.com F our years on after the introduction of femtosecond laser cataract surgery (FLACS), the debate still rages on about whether FLACS is superior to phaco in outcomes and the evidence that this is so is still sketchy. This of course allows naysayers the right to question whether the signi cant costs of FLACS can be justi ed. Whilst the jury is still out on this point, it is pertinent to point out that no new technology succeeds overnight and that time and development are needed for it to nd its place in the cataract surgery world. New technology has not only to be shown to be superior as far as visual results are concerned; it also has to prove that it is at least as safe as existing technology—in this case, phaco. Dr. Stephen Macleod raises the point of “postage stamp CCCs” and tags after a femtolaser capsulorhexes; these issues were largely from rst generation machines in 2012 and today the latest femtolaser cataract machines yield perfect, round, centered capsulorhexes in the vast majority of cases. He also brings up the point of femtolaser energy usage which should be added to the ultrasound energy used and this is a fair point although the laser energy is usually delivered within the con nes of the capsular bag whilst ultrasound energy is often deployed at or around the iris plane, nearer to the corneal endothelium. We need to think about the place of FLACS in two contexts: in normal, “standard” cataracts and in more complex cataracts. For standard cataracts, outcomes have so far not been proved superior but the role of FLACS here for the “average” cataract surgeon who may not be as skilled as an expert surgeon is signi cant as it can allow the average surgeon to attain results similar to those of expert surgeons. For complex cataracts such as polar cataracts, dense nuclear sclerosis, brotic capsules, and partially subluxated cataracts, there is growing consensus that FLACS is indeed a safer procedure and should be recommended as the preferred techinique in these cases. FLACS in 2016 is here to stay; its role in each physician’s practice will be different but ultimately it will be complementary technology that can only strengthen the cataract surgeon’s armamentarium and ensure better outcomes for patients. Editors’ note: Dr. Yeoh is on the Alcon (Fort Worth, Texas) and Abbott Medical Optics (Abbott Park, Ill.) speaker panels. As for the laser making fragmentation easier, Dr. McLeod said that is a benefit, especially for surgeons who are less comfortable with energy-reducing phaco chopping techniques. “This can also enhance patient safety in cases of loose zonules because the lens is disassembled with less effort, which can reduce zonular stress and risk of zonular dehiscence,” he said. Bringing femto to practice Once physicians decide to bring the femtosecond laser into their practices for cataract surgery, they have to prepare to talk about it with patients. As the ASCRS Refractive Cataract Surgery Subcommittee said in a 2013 article, providers have a “tremendous responsibility” in informing patients of their options as femto vs. manual “brings with it technical, ethical, and financial challenges.” 6 “We are only beginning to comprehend the benefits and complexities of this exciting new technology,” the subcommittee wrote. In addition to physicians introducing patients to FLACS, sometimes it is the patient who brings up the option. “Some patients have researched the femtosecond laser and request this by name during cataract evaluation,” said Cynthia Chiu, MD, associate professor, UCSF, adding that she only offers it in combination with premium intraocular lens use or for corneal astigmatism correction. “Due to direct imaging of the cornea, the femtosecond laser can create intrastromal AK incisions with precision in the depth of treatment. Studies are starting to report the improvement in uncorrected visual acuity using femtosecond lasers due to the reduction of the corneal cylinder. Even patients receiving monofocal IOLs can benefit from astigmatism correction because many surgeons do not offer toric IOLs below a cylinder of 1.5 diopters,” she said. Dr. Chiu said she has always been comfortable discussing premium cataract services with her patients, even prior to femtosecond laser options. “It has become a more common discussion now that lower amounts of corneal astigmatism can be well-treated at the time of the surgery,” she said. A possible negative to FLACS at the practice level could include longer operating times. Dr. Chiu said it only adds about 5 minutes to her manual phaco time at a dedicated ophthalmic ambulatory surgery center. At UCSF, where there are more regulations for the university operating room compared to private practice, Dr. Chiu said the femto laser has added about 20 minutes to operating times. The cost of the femtosecond laser to achieve refractive outcomes, such as astigmatism correction at the time of cataract surgery, is not covered by Medicare or private insurance. Thus, patients must be counseled and consent to paying for this additional charge out of pocket. Resident programs and FLACS If established physicians are still figuring out how FLACS may or may not fit into their practice, what is the responsibility of educators training the next generation of ophthalmologists? Dr. Ramanathan admitted she is still deciding how she feels about FLACS compared to traditional methods based on outcome data but thinks there is a responsibility to teach the new technology none the less. “I don’t know exactly how much femtosecond laser cataract surgery I’m going to be doing 5 years from now, but I suspect that this is the direction our field is moving; just as a lot of people were late to the phacoemulsification party and regretted it, I think we can’t be late to the femto party,” she said. “We have to see where this technology is going. … There are going to be numerous iterations to what we’re doing, but I’d rather become comfortable with the technology now and let my residents become comfortable with it, so that the learning curve for them is not so steep later.” As for when to start FLACS education for residents, Dr. continued on page 12