EyeWorld Asia-Pacific December 2017 Issue

EWAP FEATURE 27 2017 APACRS LIM Lecture: ‘Femto vs. Phaco: Friend vs. Foe?’ 2017 APACRS LIM Lecturer Chee Soon Phaik’s comprehensive survey of currently available data comparing the competing—perhaps complementary— technologies T he 2017 APACRS LIM Lec- turer, Chee Soon Phaik, MD , Singapore National Eye Centre, Singapore, is known as “a surgeon’s surgeon,” said Ronald Yeoh, MD, Singapore National Eye Centre, Singapore, delivering the citation for the pres- tigious award at the 30th APACRS annual meeting in Hangzhou, China. “If I had one of my cataracts or a subluxated lens, I know who I would go to,” he said. A renowned, much sought-after speaker around the world, Dr. Chee has earned this glowing recommen- dation through not just the usual skill and hard work, but a willing- ness to put herself out there at the service of the field—and so also her patients: while most surgeons at live surgeries might choose easy cases, Dr. Yeoh said, Dr. Chee asks for the most difficult ones. So it went with her 2017 APACRS LIM Lecture. Amid the heated debate that has constantly pit femtosecond laser-assisted cata- ract surgery against conventional phacoemulsification surgery, Dr. Chee stepped forward to set down by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer the available data to support a still relatively novel idea: that femto and phaco need not, in fact, be in competition. Rather, she argues, patients might better be served if they are treated as complementary technologies. Hotly debated Femto, Dr. Chee said, is hotly debated regarding its cost effec- tivity, significant learning curve, and the perception of it being an industry-driven technology. And yet, worldwide, over 1,000,000 laser procedures have been performed, over 1,000 laser platforms installed, and thousands of surgeons trained in the procedure. The potential for increased utility and safety, she said, has not been definitively established. While a number of large randomized control trials (RCTs) are currently in progress—she named the United Kingdom National Insitute for Health Research-funded Femto Assisted Cataract Trial (FACT) 1 and the French FEMCAT study 2 —for now, she said, there are three meta- analyses, one Cochrane analysis, and one case control study from EUREQUO data. The data The first met-analysis by Chen et al. 3 analyzed 989 eyes and 9 RCTs and found a statistically significant reduction in mean phaco energy and EPT with femto but no differ- ence in surgical complication rates and conflicting results in visual out- comes, central corneal thickness, endothelial cell counts. The second by Qian et al. 4 iden- tified four randomized and seven nonrandomized studies involving 2,941 eyes and found that femto and phaco had an anterior capsule rip (ACR) rate that was not different and that while the size of the femto capsulotomy was not different from manual, the circularity was supe- rior. The third by Popovic et al. 5 reviewing 14,567 eyes from 15 RCTs and 22 observational cohort studies found visual and refractive out- comes to be similar; femto reduced the EPT, loss of endothelial cell count, and corneal swelling, but aqueous PGE2 levels were tenfold higher and PCR rates higher with femto. Meanwhile, the Cochrane analysis by Day et al. 6 included 16 RCTs that enrolled 1,638 eyes and showed little difference in postop VA. There was a small but clinically insignificant difference in CDVA at 6 months and postop refraction prediction error (MAE) in favor of femto. Finally, the multicenter case control study based on the EURO- QUO database by Manning et al. 7 found femto visual outcome were not better, and increased postop complications. However, the study matched 2,814 femto to 4,987 phaco it did not reach target for phaco cases, non-consecutive cases—and the type of ocular comorbidities and surgical difficulty were not matched. Amid the mixed bag provided by the data considering efficacy and strength of capsulotomy; refrac- tive outcome and visual acuity; results with toric and multifocal IOLs; safety and efficacy of refrac- tive incisions; effect on endothelial cell count and ultrasound exposure; complications including prosta- glandin release, AC and retinal inflammation, PCO and PCR; and continued on page 29 December 2017