EyeWorld India March 2012 Issue

March 2012 13 EW FEATURE AT A GLANCE • Patients like to hear the word “laser” because it sounds sexy and they love to hear that there’s no knife involved • The financial burden behind acquiring the laser will not be a barrier to its widespread adoption • The costs of the procedure cannot be addressed from one standpoint and will depend on the healthcare system wherever the practice is located • The optimum location for the laser will be in the OR and not in the refractive surgery center With the femtosecond laser, the capsulorhexis can be placed precisely where the surgeon wants it Source: William W. Culbertson, MD Femtosecond lasers take center stage by Enette Ngoei EyeWorld Contributing Editor As the advanced technology moves into the spotlight in 2012, EyeWorld looks at some of the key issues surrounding its adoption worldwide in cataract surgery W ith promises of better safety, efficacy, and consistency, the femtosecond laser for cataract surgery, now commercially available in the U.S., has seen an international growth in interest as well as global competition among manufacturers. Alcon (Fort Worth, Texas, USA/Hünenberg, Switzerland) is marketing the LenSx laser in the U.S. and around the world, OptiMedica (Santa Clara, Calif., USA) is beginning distribution of its Catalys Precision Laser System in Europe after receiving CE mark approval, and Bausch + Lomb (Rochester, NY, USA) and Technolas (Munich, Germany) are promoting the VICTUS Femtosecond Laser Platform, an all-in-one platform for refractive and cataract applications. The technology is expected to be a major focus in 2012 in the U.S. and globally. But with the high costs involved in acquiring the laser, the uncertain cost-effectiveness and slowdown in workflow it brings, will the technology gain a wide acceptance? The experts EyeWorld spoke with said yes. An unstoppable technology “There’s no way to stop new technology,” said Günther Grabner, MD , director, University Eye Clinic, Paracelsus Medical University, Salzburg, Austria. For one, patients like to hear the word “laser” because it sounds sexy and they love to hear that there’s no knife involved, he explained. What’s more is there are six companies that he knows of that have spent a total of about US$2 billion in research and development of the technology. “I don’t think that there’s a way out because they will push forward and this will be a technique that will be implemented,” Dr. Grabner said. “I don’t know if it will be 3, 5, or 10 years—my guess is that it will be about 5 years. About 40% probably will have switched to this technique.” If the laser isn’t widely adopted, it will probably be because of the high price tag associated with it, Dr. Grabner said. “There are very few centers that can make a profit after spending 450,000 euro or dollars (U.S.), plus about $40-$50,000 (U.S.) per year maintenance fee, plus $300- $450 (U.S.) per case click fee,” he explained. However, according to H. Burkhard Dick, MD , chairman, University Eye Hospital Bochum, Germany, the financial burden behind acquiring the laser will not be a barrier to its widespread adoption. “As a matter of fact, we had this same discussion with femto LASIK 10 years ago and now I do femto LASIK on nearly every patient,” he said. “Initially I thought, why should I pay 450,000 euros for a device that only makes a flap? Now everyone uses it and I would not go back to microkeratomes.” A real difference? While the femtosecond laser may create more precise, well- centered, safer capsulotomies, the question remains whether the capsulotomy significantly affects outcomes. According to Rudy Nuijts, MD , associate professor, Academic Hospital Maastricht, the Netherlands, the capsulotomy is important in terms of centration of the lens, especially when surgeons are using more sophisticated premium IOLs. “Decentration and tilt of lenses is even more important because we know that with toric and multifocal lenses, if there is decentration to a certain extent, this will decrease and limit the outcome of the procedure,” he explained. For the experienced surgeon, routine capsulorhexis at a certain diameter, configuration, and placement is not a big issue, but surgeons can now guarantee that to every patient, Dr. Dick said. However, he said, while there is some data out, there have not been controlled, comparative, masked trials. “It’s not data driven, but I’m convinced,” he said. Logistical considerations The optimum location for the laser is yet to be determined. For Dr. Dick, it will be in the OR and not in the refractive surgery center. This is because it presents a problem in terms of timing. The moment the anterior capsule is opened, some elements are released. Some production of chemicals in the eye is initiated because the aqueous has continued on page 15