EyeWorld Asia-Pacific March 2018 Issue

51 EWAP DEVICES March 2018 Views from Asia-Paci c Robert Edward ANG, MD Senior consultant, Asian Eye Institute 8th Floor Phinma Plaza, Rockwell Center, Makati City, Philippines Tel. no. +63-2-8982020 Fax no. +63-2-8982002 angbobby@hotmail.com I nnovations in improving cataract surgery are always welcome. Safer, faster, more consistent are attributes that can make innovations gain traction. The femtosecond lasers were retooled from flap-making to perform functionalities such as corneal incisions, capsulotomy, and lens fragmentation to aid cataract surgery and make it easier, safer, and more consistent. Published literature confirms that circularity and sizing of capsulotomies were more consistent and less ultrasound energy is delivered because of precutting of the cataract. However, refractive and visual outcomes have not been decisively proved to be better than traditional phacoemulsification. In addition, the huge expense of purchasing the femtosecond laser, maintenance costs, and per eye click fees have dampened widespread adoption of femtosecond laser-assisted cataract surgery. The financial hurdle has opened opportunities for newer companies to develop devices that can perform choice portions of the cataract surgery. By being more specific and limited in functionality, the devices will be smaller and therefore cheaper to build and to sell. The Zepto and Aperture CTC are thermal alternatives while the Capsulaser is a laser alterative to manual capsulotomy and femtosecond laser-assisted capsulotomy. While it is true that capsulotomy is probably the most difficult part of the phacoemulsification process to master, once you have mastered it, would you need a device that you will pay for to automate it? The experienced surgeon would likely feel they do not need it unless there is a challenging case. The novice surgeon or trainee would benefit the most but if they start using this, the more they will not learn to perform their own capsulotomy. For the patient, it is difficult to justify the extra expense unless I downplay my own personal ability to perform a capsulotomy. As for the miLoop, I believe It works but widespread usage may be very difficult because you will add an expense but you still need to use the phacoemulsification machine. When I do my patient counseling, it is actually easier for them to understand the “bladeless” corneal incision aspect of femtocataract surgery than the automated capsulotomy or even the lens fragmentation. And when you start going into more specifics during patient counseling, it is difficult to avoid stoking some fear of uncertainty into traditional phacoemulsification. The bias may come from the surgeon or the counselors especially if the practice involves allowing the patient to select and charging them higher for laser-assisted cataract surgery. For me, those already with femtosecond lasers will probably not invest anymore in these devices unless they would like to offer patients a three-tiered pricing option. For those without a femtosecond laser, these devices will be a good marketing tool that will help them compete and offer “laser” cataract surgery at a cheaper cost. Editors’ note: Dr. Ang is a consultant for Bausch & Lomb (Rochester, New York). Ronald YEOH, FRCS, FRCOphth, DO, FAMS Adj. Associate Professor Duke-NUS Grad Med School 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 T hat there is a plethora of new devices on the market is at once exciting and yet confusing in some ways. Just when we thought we had cataract surgery licked with a combination of modern phaco and femtosecond laser cataract machines, along comes these new devices. Several of these devices address one of the two main benefits of FLACS: the perfectly positioned, round capsulorhexis, with the advantage of far lower cost when compared with a FLACS machine. Even the quoted US$175 disposable fee can be regarded as almost reasonable when compared to the patient interface charges that all FLACS machines charge. Of course, reducing this to the US$100-mark would make it more acceptable, bearing in mind that it would be difficult to charge patients more for this step which is hitherto uncharged in normal phaco. The possibility of these lower cost capsulorhexis devices giving us FLACS- like or superior-to-FLACS results is compelling, especially as more lens implants are being designed for capsulorhexis fixation. The Miloop device for fracturing the nucleus is interesting although there is likely to be a significant learning curve. Also, modern phaco and manual small incision cataract surgery techniques have advanced to the point where this device may be relevant in only a few cases. It also bears remembering that with new technique and technologies, new complications, some unimaginable, are possible. Prudence in adopting them is wise. Editors’ note: Dr. Yeoh declared no relevant financial interests. “ ...the huge expense of purchasing the femtosecond laser, maintenance costs, and per eye click fees have dampened widespread adoption of femtosecond laser- assisted cataract surgery. “The financial hurdle has opened opportunities for newer companies to develop devices that can perform choice portions of the cataract surgery.” - Robert Edward Ang, MD “ Just when we thought we had cataract surgery licked with a combination of modern phaco and femtosec- ond laser cataract machines, along comes these new devices. Several of these devices address one of the two main benefits of FLACS: the perfectly positioned, round capsulorhexis, with the advantage of far lower cost when compared with a FLACS machine. ... The possibility of these lower cost capsulorhexis devices giving us FLACS-like or superior-to-FLACS results is compelling... ” - Ronald Yeoh, FRCS, FRCOphth, DO, FAMS