EyeWorld India June 2013 Issue

June 2013 17 EWAP FEAturE Views from Asia-Pacific Cesar Ramon G. ESPIRITU, MD Chairman, Department of Ophthalmology, Manila Doctors Hospital Rm. 207 Doña Salustiana Medical Tower, Manila Doctors Hospital, United Nations Avenue, Ermita 1000, Philippines Tel. no. +632-5252260 Fax no. +632-5243011 loc. 4080 espiritueyemd@mac.com I n August 2011, The American Eye Center in Manila, Philippines became the first in Asia to acquire the LenSx femtosecond laser system (Alcon). Since then we have, in a short span of time, shifted our cataract cases toward 49.2% femtosecond-assisted as per 2012 figures. This has allowed us to gain region-leading experience with the technology and to reap all the benefits of the repeatable, precise, well-constructed capsulotomies and corneal incisions, as well as the marked decrease in phacoemulsification energy required to remove standard cataracts and, more importantly, challenging ones. Cases such as rock-hard cataracts, intumescent and subluxated lenses are now handled with less difficulty and with increased success. Since 39.6% of our cases choose advanced technology IOLs (AT-IOLs), postoperative emmetropia is extremely important in assuring patient satisfaction. The keys to this are, first, a predictable effective lens position (ELP) and, second, a consistent surgically-induced astigmatism (SIA) from our incisions. Femtosecond-produced capsulotomies that are programmed in size and location, that are almost identical in every case, and that ultimately ensure complete capsular bag capture have definitely contributed to achieving preoperatively predicted ELPs. Being able to produce precise corneal incisions with regards to size, architecture, and location have significantly reduced the variability of SIAs compared to manually produced ones. In addition, femtosecond laser arcuate cuts that are made at precise depths and widths have justifiably made us take a second look at this mode of astigmatism management. A greater flattening effect with laser incisions has been observed. All that remains is to establish any undesired regression over time. With incisions, capsulotomies, and nuclear fragmentation now computer controlled, and with upgrades providing improved imaging, the logical progression of this technology into the future is to minimize, if not eliminate, positioning error through eye registration. Primary, secondary, bimanual and arcuate incisions can then be made in the desired axes and distances from the limbus. Capsulotomies can then be centered on the surgeon’s choice of either the pupil center or visual axis. A feature that will aid in positioning toric IOLs without having to mark should also come in the near future. These developments will, without question, raise the bar and widen the gap between FLACS and phacoemulsification. We should then see a rapid shift of early skeptics to convinced converts. Editors’ note: Dr. Espiritu is a consultant for Alcon and LenSx but has no financial interests related to his comments. Sri GANESH, MD Chairman and Managing Director, Nethradhama Hospitals Pvt. Ltd. 26/14, Kanakapura Main Road, 7th Block Jayanagar Bangalore 560082 India Tel. no. +91-80-26088000/+91-98451294740 Fax no. +91-80-26633770 chairman@nethradhama.org A s cataract and refractive surgeons, we are constantly in pursuit of ensuring that our patients attain maximum uncorrected visual acuity after our interventions. Femtosecond laser-assisted cataract surgery represents a potential paradigm shift in cataract surgery, but it is not without controversy. Femtosecond lasers presumably allow for more square architecture and stable incisions, which are more resistant to leakage, and are thought to reduce the incidence of endophthalmitis. However, femto does not work well near limbus, corneal vascularization/pannus or scars. In such cases a more central corneal incision is created by femto. This induces more astigmatism. Also, the clear corneal or limbal relaxing incisions for treating astigmatism are not very predictable and using toric IOLs may be a better option. The femtosecond laser is able to create a near perfect, round opening in the anterior capsule which is believed to reduce the incidence of posterior extension of the tear and decentration of the IOL. On the contrary, decentration of IOL is multifactorial, depending upon capsular fibrosis/contraction, size and type of IOL, position of haptics, zonular stability and so on. In cases of incomplete rhexis following femtolaser, forceps are needed to remove the anterior capsule. Femto laser also cannot be used in smaller pupils. As far as lens fragmentation is concerned, femtolaser is thought to reduce the average time and ultrasonic energy required to break up and remove the lens. However, one needs to focus the laser at least 800 microns away from the posterior capsule or there is a high risk of PC tear and nucleus drop. It has also been seen that femtolaser is unable to separate the posterior plate in hard cataracts causing incomplete fragmentation. Also, an incomplete pneumodissection and absence of anterior cortical frills makes cortex removal difficult. Most of the complications during standard phaco like PC rent occurs during I/A and this cannot be avoided with the femto. As far as patient experience is concerned, there is increased pain and discomfort due to the large suction cup. At the end of the surgery, the eye looks red due to SCH—not cosmetically acceptable in a premium surgery. Other downsides of femto cataract include increased operative time, longer patient waiting time and a two-stage procedure. There is no clinically significant difference in vision compared to phaco, but with a significant increase in cost of surgery. Overall, poor value for money. Newer technology should improve surgical efficiency, patient comfort and safety or provide a significant clinical benefit or reduce cost of treatment. This is yet to be clearly established with femto-assisted cataract surgery. Editors’ note: Dr. Ganesh is a consultant for Abbott Medical Optics (Santa Ana, Calif., USA), Carl Zeiss (Jena, Germany), Hoya Surgical Optics (Chino Hills, Calif., USA), Bausch+Lomb, and Schwind eye-tech-solutions (Kleinostheim, Germany), but has no financial interests related to his comments.