EyeWorld India March 2012 Issue

March 2012 8 EW FEATURE C ataract surgery is generally considered a near-perfect procedure, a routine, high-volume procedure with exceptionally high success rates and low complication rates, but challenges do remain and the expert panelists in a recent EyeWorld Asia-Pacific Roundtable are all current participants in “one of the most exciting adventures in cataract surgery for many, many years,” said Graham Barrett, MD, looking into a new technology that promises to improve on perfection. “We’re in quite a unique position because we have with us people who have experience with two of the four major femtosecond laser platforms, and results from regions where that experience is available,” said Prof. Barrett at the beginning of the roundtable. “Particularly in our region, it looks to me as though we may actually be leading the way because we have a greater variety of systems available compared with other more regulated markets.” The perfect rhexis? Graham Barrett (GB): Let’s start off on a small scale, and look at each step of the cataract operation, and how this technology may be useful, and then we’ll step back and look at the broad picture, including ergonomics and cost effectiveness. I think all of us immediately understand the utility of this technology in performing capsulorhexis. Making the rhexis symmetrical, round, and the same size, consistently, is something that not anyone can do perfectly in every case. So this, to me, was the immediate attraction of this technology. Would you agree that this seems to be the primary advantage? Kasu Prasad Reddy (KPR): I totally agree; for me fragmentation is helpful, but to be able to make a rhexis precise even manually is exciting, and for us surgeons, the precision and repeatability this technology offers is a milestone. Cesar Espiritu (CE): Yes. The precision and repeatability of creating the rhexis is the beauty of it. You have a perfectly round and smooth-edged rhexis where you can vary the size. There are even special cases where you are still able to make a very good rhexis, such as in intumescent and even slightly subluxated lenses, which otherwise would be a definite challenge if done manually. As far as incisions, it’s the same thing. It’s impossible for you to create the exact same incision every time. You’re also looking at trying to minimize if not avoid tears, because you have a nice cut. You can determine the exact size, the exact length, and position it wherever you want. GB: So you think incisions may rival the utility of creating the rhexis? CE: Well, the rhexis for me would still be the number one advantage. But I’m not discounting any of the other advantages. Chee Soon Phaik (CSP): I think that’s where the value lies in, being able to be certain that the rhexis is perfect every time. That’s really difficult. Dr. Reddy does an excellent rhexis. You look at it, and visually, it looks really round. But if you take it out of the eye you might see it’s not perfectly round. The other point about the quality of the rhexis is that data emerging from studies indicate that the capsule edge is actually stronger than that achieved in a manual tear. It was a great surprise to me to learn this, because my concept was that the laser capsulotomy might look intact but it would not be able to withstand manipulation, particularly with the manipulation required in the hard cataracts you see in Asia. However, the belief is that the laser is able to weld that cut edge, so that it actually strengthens that capsulotomy, making it more robust. GB: Playing the devil’s advocate—taking it for a given that you can make a better rhexis with Femtosecond lasers: Improving on perfection? EyeWorld Asia-Pacific Roundtable by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer ABOUT THE PARTICIPANTS Graham BARRETT, MD , Lions Eye Institute and Sir Charles Gairdner Hospital, Perth, Western Australia, focuses mainly on cataract surgery, but also performs refractive surgery. “I’m standing by the edge of the pool—like most surgeons in the rest of the world—looking at this”—femtosecond laser cataract surgery—“with great interest,” he said. “ CHEE Soon Phaik, MD , Cataract Surgery Service, Singapore National Eye Centre (SNEC), Singapore, was trained in plastic surgery as well as ocular inflammation, but is now one of the most renowned cataract surgeons in the region. “I’ve been watching this technology very closely,” she said. “I have a very strong interest in asking a lot of questions to people who’ve had experience with the different industry players, and in exploring all the different options.” Recently, Prof. Chee was given the opportunity to perform cataract surgery using the femtosecond laser at Dr. Reddy’s clinic in Hyderabad. Cesar ESPIRITU, MD, American Eye Center, Manila, Philippines, was trained in cornea and infectious disease, but developed his interest and skills in cataract surgery in his group practice. He and his colleagues in the group practice were the mentors of Melvin Sarayba, MD, one of the developers of the LenSx platform (formerly LenSx, Aliso Viejo, Calif., USA, now Alcon, Fort Worth, Texas, USA/Hünenberg, Switzerland). “He generated our interest in the machine early on,” Dr. Espiritu said. “We’ve been following the development of the machine and we were really keen on acquiring it as soon as we got the chance. Finally, we were able to pull it off – we got the first of such machines in Asia.” Dr. Espiritu is thus one of the first surgeons to have experience with the commercial machine. Kasu Prasad REDDY, MD , Hyderabad, India, started with excimer lasers in England in 1991 and had been interested in laser-based solutions for presbyopia early on, when he was introduced to the prototype Femtec femtosecond laser (formerly 20/10 Perfect Vision, Heidelberg, Germany, now Bausch + Lomb, Rochester, NY, USA) for cataract surgery. “They got me the prototype and placed it in Hyderabad,” he said. “That was about one year ago, around last September or October 2011.” Dr. Reddy now has one of the widest experiences with femtosecond laser cataract surgery today, having completed over 450 cases. Unlike Dr. Espiritu, Dr. Reddy has been involved with femtosecond laser cataract surgery from its earliest developmental stages.