EyeWorld Asia-Pacific September 2014 Issue

46 EWAP CAtArACt/IOL September 2014 Views from Asia-Pacific Keiki MEHTA, MD Mehta International Eye Institute & Colaba Eye Hospital Mumbai, India Tel. no. +91-22-22151676 Fax no. +91-22-22150433 keiki_mehta@yahoo.com F emtosecond laser cataract surgery is a new advance which has gained wide acceptance all over the world. However, its adoption in Asian countries has been comparatively slow, partly because patients cannot appreciate the difference engendered by this technology by its very high price as compared with a regular phaco surgery. Not only does it take much longer and leave a far redder eye, it has more discomfort and costs virtually six times more than regular cataract surgery in India. Though the base cost of the instrumentation is high, from an Asian’s surgeons viewpoint it is the cost of the consumables and the subsequent cost of maintaining the laser which erodes into the basic profits. The additional problem is that mediclaim and insurance facilities consider it a super premium surgery and are not willing to cover the cost beyond the basic cost of the implant and an add-on surgical cost. In addition, the cost of the duties applicable on the instruments enhances still further and with availability of loan at 17% means that unless one has a very high volume, its chances of financial viability is very low. Invariably, the femtosecond is purchased to demonstrate that in one’s center has the latest technology, but its financial viability is extremely difficult. Major centers in India have commenced adopting the femtosecond laser but enquiries invariably show that less than 10–12% of their regular list cases are done using the femtosecond surgery. Undoubtedly, the advantages of the superb well-centered rhexis has its advantages; however, with the modern phacoemulsification techniques, with good capsular polishing and good lenses, phimosis of the capsule with change in IOL position has become extremely rare and does not offset the excess cost of the equipment. If one needs to summarize: Femtocataract surgery is exceptional technology; however, it will still need time to be adopted as routine in countries where insurance does not subscribe to offset the cost and where cataract surgery tends to be price sensitive and where volumes in surgery are the norm and not the exception. Editors’ note: Dr. Mehta has no financial interests related to his comments. has a lot of variability because of the medium.” The femtosecond lasers, however, do exactly the same thing every time, he said. “Now we have an invariable method operating on a variable medium—that’s why the femtosecond laser results with AK are better than we get with blades,” he said. Vance Thompson, MD , associate professor of ophthalmology, University of South Dakota School of Medicine, Sioux Falls, SD, U.S., likewise believes that the femtosecond laser reduces unpredictability. “When we have a diamond blade enter the corneal collagen, there’s a compressive issue where there’s tissue being pushed in front of the blade,” Dr. Thompson said. “Oftentimes the beginning of the incision is a slope that’s shallow and then gradually gets to the appropriate depth, but that depth may never be at the one that you intended.” As a result, manual AK techniques lead to variability in incision architecture and depth, he said. By contrast, OCT-guided femtosecond procedures are extremely precise. “You’re now dealing with transitioning from human-measured variables to computer-measured and applied variables,” Dr. Thompson said. “If you’re going for a 45-degree arc, you are going to get it precisely, and if you’re going for a OCT- guided 85% depth, you’re going to get that precisely.” Dr. Thompson likes the fact that the AK effect is titratable with the femtosecond laser since practitioners can open incisions as needed. He combines this with the use of intraoperative aberrometry. “I take my aberrometry measurement in surgery and if it is less than the preoperative measurements, I decide not to open the AK,” he said, noting that sometimes the unopened limbal or AK incision is enough to reduce the patient’s astigmatism. However, William F. Wiley, MD , assistant clinical professor of ophthalmology, University Hospital Medical Center, Cleveland, Ohio, U.S., is not totally convinced. While he agrees that theoretically such titratability is possible, he thinks more study is needed. “In practice it’s still early, we’re still determining what effect an unopened incision has compared to an opened one,” Dr. Wiley said. For those who rely heavily on intraoperative aberrometry in determining needed treatment amounts, there may be practical difficulties in performing femtosecond AKs, he said. “The downside that I see with the current technology femtosecond lasers is the fact that you’re making those [AK] treatments before you’ve started cataract surgery,” Dr. Wiley said. He prefers to check the preoperative measurements with aphakic intraoperative aberrometry to ensure this is accurate. However, creating a femtosecond AK at this point may be difficult in some practices because the femtosecond laser may be located elsewhere, he explained. “The reality is doing a double dock with the current technology where often the cataracts are being Assessing - from page 45