EyeWorld Asia-Pacific March 2018 Issue

EWAP CATARACT/IOL March 2018 33 Views from Asia-Paci c FAN Wei, MD, PhD Department of Ophthalmology, West China Hospital, Sichuan University 37 Guoxue Ln., Chengdu, 610041, China Tel. no. +86-28-85422542 Fax no. +86-28-85422542 fanwei55@yahoo.com F emtosecond laser-assisted cataract surgery (FLACS) has been supposed to bring advancements to conventional phacoemulsification cataract surgery (PCS) by improving surgical safety and accuracy leading to better visual outcomes. Approved for cataract surgery by the U.S. Food and Drug Administration (FDA) in 2010, more than 120,000 eyes globally had undergone FLACS by 2013. However, data from earlier and recent studies show that there are no significant benefits of FLACS over PCS, in terms of visual and refractive outcomes and overall complications. Given additional concerns of cost effectiveness, questions and controversies have risen on the superiority of FLACS over PCS. The emergence of phacoemulsification together with advances in measurement technology and the invention of foldable IOLs have led to revolutionary improvements in modern cataract surgery. These progresses have made cataract surgery a procedure with increasingly precise postoperative refractive outcomes. In the meantime, they also have raised the bar for newer technology, i.e. here FLACS, to bring such huge advancements once more. Arguably, expectations for FLACS should be reasonable. Since laser treatment is able to provide better precision of capsulorhexis, nucleus fragmentation, and corneal astigmatism treatment (accurate keratotomy, AK), and FLACS does show advantages over PCS in some outcomes related to these procedures, I personally regard it as an “icing on the cake” for PCS. The question is how to make better use of FLACS for patients in order to realize its advantages? Recently, a cohort study by Lundstrom et al. highlighted an important issue regarding the selection of patients for FLACS, since the outcomes of the procedure are strongly related to preoperative characteristics. While I agree completely with the authors on this matter, I am also quite positive about the use of FLACS, especially for patients in the following situations: 1. Presbyopia correction with corneal astigmatism of 0.75–1.50 D; 2. Cataract surgeries involving hard nuclei, zonular weakness/partial dialysis, and corneal endothelial diseases. Corneal astigmatism correction is critical for patients requiring presbyopia correcting IOLs. FLACS + AK provides these patients with better visual acuity and quality, and is even more cost effective since there is no additional charge for AK and no need for toric or toric multifocal IOLs. In our practice, AK accounts for about 25% of all FLACS cases. Additional advantages of FLACS are benefits in complicated cataract cases related to decreased ultrasound energy and time, decreased endothelial cell loss and corneal edema, and easier management of dislocated lenses, among others. Further studies are needed to evaluate long- term efficacy of FLACS in these cases. Editors’ note: Dr. Fan declared no relevant financial interests. Hiroko BISSEN-MIYAJIMA, MD, PhD Professor, Tokyo Dental College Suidobashi Hospital 2-9-18 Kandamisaki-cho, Chiyoda-ku, Tokyo, Japan 101-0061 Tel. no. +81-3-5255-1856 Fax no. +81-3-5275-1912 bissen@tdc.ac.jp I t has been about 10 years since the first clinical case of femtosecond laser- assisted cataract surgery (FLACS) was reported. At first, we were excited to have a new technology; however, after a little while, some criticism came up. The criticism is not about the surgical technique or the surgical outcomes of FLACS, but the benefit of FLACS over current cataract surgery. As this review mentions, fair comparison of FLACS and manual phacoemulsification is difficult since patient selection varies. The patients who received FLACS had lower density of lens opacity and fewer ocular comorbidities. On the other hand, we see the benefit of FLACS in complicated cases such as weak zonules, lens subluxation, hard nucleus, and mature cataract. In these cases, the lens aspiration following the perfect anterior capsulotomy and lens fragmentation becomes easier with FLACS. It is important to evaluate FLACS in extensive cases. The necessary improvement in FLACS is the corneal incision. The article mentioned that FLACS-specific complications were most commonly related to the corneal incision. In our study of 529 consecutive Japanese eyes, incomplete corneal incisions were found in 8.3% due to an arcus senilis and neovascularization. We can avoid the laser application to these areas; however, the location of the incision becomes closer to the corneal center and the surgically induced astigmatisms increases. Thus, the location, design, and laser settings for corneal incision should be considered further. Finally, we wonder if FLACS is worth the higher cost to the patients. When the patient asks if FLACS is better than manual phacoemulsification, I answer that the final visual acuity would be the same, but the surgical finishing inside the eye differs. A good example is hemming up the trousers by hand or with a sewing machine. The final length would be the same, but the accuracy of stitch is superior with the machine. The accuracy of FLACS has definitely potential to improve the technique of cataract surgery and we would like to see more positive feedback. Editors’ note: Dr. Bissen-Miyajima is a consultant for Alcon (Fort Worth, Texas) and Johnson and Johnson Vision (Jacksonville, Florida). Review - from page 31 “ ...we wonder if FLACS is worth the higher cost to the patients. When the patient asks if FLACS is better than manual phacoemulsification, I answer that the final vis- ual acuity would be the same, but the surgical finishing inside the eye differs. ” - Hiroko Bissen-Miyajima, MD, PhD “ The emergence of phacoemulsification together with advances in measurement technology and the inven- tion of foldable IOLs have led to revolutionary improve- ments in modern cataract surgery. These progresses have made cataract surgery a procedure with increas- ingly precise postoperative refractive outcomes. In the meantime, they also have raised the bar for newer tech- nology, i.e. here FLACS, to bring such huge advance- ments once more. ” - Fan Wei, MD, PhD