EyeWorld India March 2012 Issue

March 2012 15 EW FEATURE access to the lens material, which could cause the pupil to constrict, he said. Dr. Grabner said the best location for the laser depends on the set-up of the clinic. “I have a clinic at the University Eye Clinic in Salzburg that has three fully-equipped ORs plus a laser room,” he said. “We probably will need an additional room in front to place the laser; all the initial cuts can be done there and then the patients will be brought into the ORs.” Dr. Grabner also knows of smaller set-ups that have placed a laser in the OR and use one operating table for both the femtosecond incision plus the remainder of the surgery. The best working model has John S. M. CHANG, MD Director, Guy Hugh Chan Refractive Surgery Centre Hong Kong Sanatorium and Hospital 8/F Li Shu Pui Block, Phase II 2 Village Road, Happy Valley, Hong Kong Tel. no. +852-2835-8885 Fax no. +852-2835-8887 johnchang@hksh.com F emto cataract will eventually replace phaco except for white cataracts. Most laser companies claim they can do grade 4 cataracts already. For now it is a “no knife” procedure which will be very appealing to the patient and a very strong marketing tool. However, once we have the fragmentation mastered we will only need to suck out the nuclear fragments - no ultrasound will be needed. This significant “saving” in endothelial cells will justify the use of this technology for everyone; we may need these cells since we are now living longer. Every patient will want this, therefore the Government and insurance companies will eventually have to pay for this. Money cannot buy your own endothelial cells back and other people’s cells can reject. In Asia, one important consideration is whether the suction rings can fit into the small Asian eyes. With femtoLASIK, we already have some problems with small eyes, even though the younger LASIK generation are already taller and have bigger eyes. The older ladies in their seventies are much smaller; even canthotomies may not make the rings fit in. The size of the laser is another issue in many Asian cities. In cities like Tokyo and Hong Kong, prime offices the size of a toilet can cost 1 million U.S. dollars. So the cost of placing a laser in the office will also have to factored in. Smaller lasers will have an advantage. We hope to start our first cases in June this year. Editors’ note: Dr. Chang is a consultant for Abbott Medical Optics (Santa Ana, Calif., USA) and receives travel support from Technolas Perfect Vision. Johan A. HUTAURUK, MD Director, Jakarta Eye Center Jl. Cik Ditiro 46, Menteng, Jakarta 10430 Tel. no. +62-21-3193-5600 Fax no. +62-21-390-4601 johan.hutauruk@jakarta-eye-center.com I believe that femtosecond laser will be the future for cataract and refractive surgery, mainly because it offers safety and precision, but the very high price of this technology doesn’t help the adoption for surgeons to switch their techniques, especially for the femtosecond cataract surgery. LASIK flap creation with microkeratome was comparable with the femtosecond flap maker about 10 years ago, because not many surgeons could hold their breaths for more than 1 minute while creating the flap with the earlier technology. But now, almost every LASIK surgeons would prefer femtosecond laser to create corneal flap; it is fast, more precise and safe. Surgeons who are willing to position themselves to become early adopters in this technology should receive some appreciation from the ophthalmic industries by giving them half of the intended market price of the machines. Those surgeons were the ones who experienced the “pain” with the imperfect technology and shared their thoughts to improve the technology, but they also paid more compared to the new surgeons who can avail of better machines at a lower price. I am currently using the femtosecond laser to remove cataract; it nicely creates a perfect capsulorhexis, makes the main and second port corneal incisions and cuts the lens into several quadrants for more efficient phacoemulsification. However, as the first of its kind, this technology slows down everything and above all, the price tag for the machine plus per case “click” procedure is way too expensive. Some have said that perfect capsulorhexis with femtosecond laser would help for better effective lens position, which translates into better accuracy in refractive outcomes after cataract surgery. Yes, I fully agree, but in my opinion, accurate biometry, advanced IOL formula and IOL designs are still the major contributors to achieve targeted refraction after surgery. While few surgeons are having some inconveniences with the new technology, their experiences will certainly be useful for the development of the next generation femtosecond laser, with better performance and lower price for others to obtain. Yes, we should go for femtosecond cataract surgery; it is currently slower than conventional surgery, but it is safer, and we will have a better future with this new technology. Editors’ note: Dr. Hutauruk has no financial interests related to his comments. Views from Asia-Pacific to be worked out in practice, Dr. Nuijts said, and it’s too early in his experience to recommend what would be the best position in terms of strategy and workflow. Will the laser be shared among physicians? Dr. Dick said, “Absolutely. Unless you have a volume of 3,000, it’s mandatory. You have to have a large volume to make it pay.” Surgeons who have a very low volume will have to share the laser with five to eight other surgeons with the same volume, he said. Addressing costs How the laser will be paid for is still being explored. According to Dr. Grabner, in premium lens cases, costs will probably be assigned to the patient. continued on page 22 Femtosecond - from page 13