EyeWorld Asia-Pacific June 2016 Issue

June 2016 EWAP FEATURE 17 capsulotomy integrity after femtosecond laser-assisted cataract surgery. Ophthalmology 2014 Jan;121(1):17-24. 3. Ostovic M, Klaproth OK, Hengerer FH, Mayer WJ, Kohnen T. Light microscopy and scanning electron microscopy analysis of rigid curved interface femtosecond laser-assisted and manual anterior capsulotomy. J Cataract Refract Surg. 2013 Oct;39(10):1587-92. 4. Schultz T, Joachim SC, Kuehn M, Dick HB. Changes in prostaglandin levels in patients undergoing femtosecond laser- assisted cataract surgery. J Refract Surg. 2013 Nov;29(11):742-7. 5. Chen H, Lin H, Zheng D, Liu Y, Chen W, Liu Y. Expression of Cytokines, Chmokines and Growth Factors in Patients Undergoing Cataract Surgery with Femtosecond Laser Pretreatment. PloS One . 2015 Sep 2;10(9):e0137227. 6. Rossi M, Di Censo F, Di Censo M, Oum MA. Changes in Aqueous Humor pH After Femtosecond Laser-Assisted Cataract Surgery. J Refract Surg . 2015 Jul;31(7):462-5. 7. Mencucci R, Matteoli S, Corvi A, Terracciano L, Favuzza E, Gherardini S, Caruso F, Bellucci R. Investigating the ocular temperature rise during femtosecond laser lens fragmentation: an in vitro study. . 2015 Dec;253(12):2203-10. 8. Diakonis VF, Yesilirmak N, Sayed-Ahmed IO, Warren DP, Kounis GA, Davis Z, Cabot F, Yoo SH, O’Brien TP, Donaldson KE. Effects of Femtosecond Laser-Assisted Cataract Pretreatment on Pupil Diameter: A Comparison Between Three Laser Platforms. J Refract Surg . 2016 Feb 1;32(2):84-8. 9. Barry P. FLACS ESCRS Study. Paper presented at: XXXIII Congress of the ESCRS; September 7, 2015; Barcelona, Spain. 10. Ewe SY, Abell RG, Oakley CL, Lim CH, Allen PL, McPherson ZE, Rao A, Davies PE, Vote BJ. A Comparative Cohort Study of Visual Outcomes in Femtosecond Laser-Assisted versus Phacoemulsification Cataract Surgery. Ophthalmology . 2016 Jan;123(1):178- 82. 11. Ewe SY, Oakley CL, Abell RG, Allen PL, Vote BJ. Cystoid macular edema after femtosecond laser-assisted versus phacoemulsification cataract surgery. J Cataract Refract Surg . 2015 Nov;41(11):2373-8. 12. Asena BS, Kaskaloglu M. Comparison of the efficacy and safety of femtosecond laser capsulotomy between mature and non-maturecataracts. Lasers Surg Med . 2016 Apr 22. doi: 10.1002/lsm.22509. [Epub ahead of print] Editors’ note: Dr. Safran is in practice in Lawrenceville, New Jersey. He declared no relevant financial interests. by Ronald Yeoh, MD F LACS was introduced to the cataract world at large in 2011 and it has had a polarizing effect on eye surgeons, health economists, and healthcare providers. On the one hand, there are the enthusiastic proponents who believe that this new technology is the greatest thing since sliced bread and that it is all good and wonderful. Unbridled enthusiasm and hype has undoubtedly done FLACS a disservice. On the other hand, there are the naysayers who highlight all the limitations and disadvantages of this technology and pronounce that it is all bad. The truth, as with most contentious issues, is that there is a middle ground where FLACS may find its place. For any new technology to be adopted as the preferred technology by all cataract surgeons, it has to be either better, safer or cheaper than the existing state of the art technology. Better? As Dr. Safran points out in his article and as we all know, there is little concrete evidence in the literature indicating superior refractive results from FLACS, whether from more precise and better shaped capsulorhexes/effective lens positions or from more precise incisions. However, we should remember that not every surgeon is an expert surgeon and that it takes years of practice and experience for a beginning surgeon to achieve the skills, slickness, and success of the expert surgeons. We all recognize that the manual capsulorhexis is one of the most challenging steps in phaco surgery and if FLACS allows a young surgeon to create capsulorhexes as good as or better, then it surely has a role in smoothening the learning curve. The femtolaser fragmented nucleus is also easier to remove, necessitating less maneuvering. Apart from allowing the average surgeon to attain quality results, another area where the advantages of FLACS are compelling is in handling the more complex cataracts such as posterior polar cataracts, subluxated cataracts, dense and white cataracts. FLACS is being used more and more for performing cataract surgery more safely in eyes with posterior polar cataracts. 1 While it is true that white cataract nuclei cannot be cut by the laser, there is increasing evidence that the femtolaser capsulorhexes in white cataracts are consistent with a very low rate of anterior radial tears or Argentinian flag sign (Comparative Evaluation of Femtosecond Laser Assisted Cataract Surgery and Conventional Phacoemulsification in White Cataract, Dr Jeewan Titiyal et al. In press: Clinical Ophthalmology). Safer? Safety issues center on the higher incidence of anterior radial capsular tears from more jagged femtosecond laser-created capsulorhexes and the oft quoted paper is Vote’s paper. 2 However, several other publications have since quoted much lower rates of anterior radial capsular tears and, indeed, the FLACS platforms in 2016 provide free-floating, round anterior capsules in almost all cases. 3,4 The issue of post-FLACS miosis has been recognized since the early days of FLACS and the use of nonsteroidal anti-inflammatory drops with the dilating regimen has neatly solved the problem. 5 The reduction in ultrasound energy usage in moderate to dense nuclei has been well documented in the literature 6 and we are all cognizant that excessive ultrasound energy in the anterior chamber is detrimental to the corneal endothelium. We are unaware of any such similar effect from the use of focused femtosecond laser energy on the lens. It must be remembered that although we have had FLACS for 5 years, this is still nascent technology in which modifications in surgical technique are needed, complications are being ironed out and optimizations are being carried out. Cheaper? This of course is the Achilles heel of FLACS; it is undoubtedly too expensive for what it offers and both sides of the fence agree on this. If there is one thing that industry needs to do to make this enabling technology more available to all surgeons, it is to review the pricing strategy and work out a payment model that allows some return on R&D investment and yet not price itself out of the market. If this can be achieved, I have little doubt that the advantages of more consistently round, better sized and positioned capsulorhexes together with lower ultrasound energy dispersal will find a more receptive market. EWAP References 1. Vasavada AR, Vasavada V, Vasavada S, Srivastava S, Vasavada V, Raj S. Femtodelineation to enhance safety in posterior polar cataracts. J Cataract Refract Surg . 2015 Apr;41(4):702-707. 2. Asbell RG, Davies PE, Phelan D, Goemann K, McPherson ZE, Vote BJ. Anterior capsulotomy integrity after femtosecond laser- assisted cataract surgery. Ophthalmol . 2014 Jan;121(1):17-24. 3. Day AC, Gartry DS, Maurino V, Allan BD, Stevens JD. Efficacy of anterior capsulotomy creation in femtosecond laser–assisted cataract surgery. J Cataract Refract Surg. 2014 Oct; 40(12):2031-2034. 4. Roberts TV, et al. Anterior capsule integrity after femtosecond laser-assisted cataract surgery. J Cataract Refract Surg . 2015 May;41(5):1109-10. 5. Yeoh R. Intraoperative miosis in femtosecond laser-assisted cataract surgery. J Cataract Refract Surg . 2014 May;40(5):852-853. 6. Hatch KM, Schultz T, Talamo JH, Burkhard Dick H. Femtosecond laser–assisted compared with standard cataract surgery for removal of advanced cataracts. J Cataract Refract Surg . 2015;41:1833–1838. Editors’ note: Dr. Yeoh is on the Alcon (Fort Worth, Texas) and Abbott Medical Optics (Abbott Park, Ill.) speaker panels. Is there a place for femtosecond laser assisted cataract surgery (FLACS) in 2016?