EyeWorld Asia-Pacific June 2020 Issue

CATARACT 24 EWAP JUNE 2020 technology in residency and fellowship allows for greater supervision during a learning curve. William Trattler, MD, said he’s a “huge advocate” for Ƃ -] w`} Ì iÃ«iV>Þ useful for creating a centered capsulotomy, fragmenting the lens, and making marks for alignment of toric IOLs. Dr. /À>ÌÌiÀ Ã>`i w`Ã Ƃ - Ài`ÕViÃ y>>Ì LÞ reducing phaco energy, and this results in less corneal edema. However, there are some differences in surgical technique with femto compared to standard phaco, and it is therefore helpful for residents and fellows to gain surgical experience with femto during their training. At his center, Dr. Trattler said patients who elect to have a presbyopia-correcting or toric IOL have the option for FLACS included. It’s also available to patients who might want it for arcuate incisions. A recent study of 189 eyes by Denise Visco, MD, found that femtosecond arcuate incisions provided a predictable improvement in >ÃÌ}>ÌÃ] ÜÌx°n¯ i`} Õ« ÜÌä°x v >ÃÌ}>ÌÃ À less. 2 Dr. Donaldson also uses the laser on all of her patients who have opted for astigmatism and/or presbyopia correction at the time of cataract surgery. She also uses it as a tool for some challenging cases, such as white cataracts, dense cataracts, traumatic cataracts, loose zonules, Fuchs dystrophy, and very shallow anterior chambers. Many studies performed over the last decade have not found >Þ Ã}wV>Ì VV> LiiwÌ of FLACS over conventional cataract surgery. 3 So, it begs the question: Is the femtosecond laser on its way out of cataract surgery or here to stay? Dr. Donaldson thinks it will remain a tool for premium cataract surgeries. “With the decreasing reimbursement for cataract surgery, surgeons will continue to seek out upgrade options to support their practice. These upgrades are a service to our patients, as they provide >``Ì> LiiwÌÃ Ì ÃÕÀ}iÀÞ] while at the same time, they >Ü ÕÃ Ì «ÀÛi Ìi w>V> «Àwi vÀ ÕÀ «À>VÌVi]» Ãi Ã>`° What’s more, Dr. Donaldson said femtosecond lasers have become more affordable for physicians with companies offering options to help offset an Ì>] >À}i w>V> VÌiÌ° Steven Safran, MD, said he thinks FLACS is a “pretty worthless technology.” “To me, the laser doesn’t offer any advantage over manual surgery,” Dr. Safran said, explaining that he doesn’t see ÀivÀ>VÌÛi] Ã>viÌÞ] À ivwV>VÞ LiiwÌÃ Ì ÕÃ} Ìi >ÃiÀ cataract surgery. He also said it can add to surgical time. “If we’re going to teach residents how to do surgery, we need to teach them how to do things manually,” Dr. Safran said. “They are never going to have another chance to learn how to properly handle tissue, to learn how to do a proper capsulorhexis. Young surgeons will have the opportunity after ÌiÞ wÃÀiÃ`iVÞ Ì `i different lasers, but surgeons in training have a unique opportunity to learn and gain experience in how to physically handle and manipulate tissue on live patients with experienced instructors overseeing them. There are many things that a laser cannot do and situations for which the laser cannot be utilized, and these manual skills will be necessary for any surgeon to be successful at handling complex issues, whereas using a laser is not. Many top surgeons have either abandoned FLACS or never used it, but they all have in common excellent manual skills and judgment learned from good training and experience.” When FLACS emerged as a new technology, Dr. Safran evaluated its capabilities and, in the end, said he thought it would be like “putting training wheels on a 10-speed bike.” “If you need training wheels, you need them, but if you don’t, they’re just going to slow you down,” he said. As for the laser’s ability to Screen image showing the plan for femto, with the fragment pattern, capsule, capsular toric marks, and corneal marks for aligning the toric IOL. Source: William Trattler, MD