Femtosecond Laser Cataract Surgery: Present and Future

Experience With 1200 Cases

Roger F. Steinert, MD: Hello. I am Dr. Roger Steinert, Director of the Gavin Herbert Eye Institute and Professor and Chair of Ophthalmology at the University of California-Irvine. Welcome to Medscape Ophthalmology Insights, coming from the American Academy of Ophthalmology (AAO) meeting in Chicago. Joining me today are Dr. Burkhard Dick and Dr. Bill Trattler. Dr. Dick is Professor and Chair at the Center for Vision Science, Ruhr University Eye Hospital, in Bochum, Germany, and Dr. Trattler is Director of Cornea at the Center for Excellence in Eye Care in Miami, Florida.

We will be discussing the latest developments in femtosecond lasers for refractive cataract surgery. We would like to begin by exploring the general concepts of how this is playing out in practice. Dr. Dick, you have done about 1000 cases at this point, which is one of the largest experiences in the world. Bill and I, being from the United States, are a little further behind you, but each of us has our own perspectives, both from international as well as local use. How is this fitting into your practice pattern? How have you altered things, and what is special about this technique to have performed so many cases?

H. Burkhard Dick, MD, PhD: We started in the middle of December, very conservatively, because I wasn't sure if there would be surprises. From then on, the interest started to increase tremendously. Germans trust technology -- this may be one reason for the interest. The other reason was that the results were very good. We have a preoperative counselor who explains the different options -- premium intraocular lenses (IOLs) as well as the laser. My business plan was for 2 years and 600eyes, but we had already completed that after 6 months. We have already performed 1200 cases on a commercial basis.

It perfectly fits into the practice. The additional time is only 1-2 minutes. The procedure is faster because the aspiration is faster, and the capsulotomy is already done. With the Catalys™ (OptiMedica; Sunnyvale, California), it is about 2.5 minutes for the entire procedure.

Dr. Steinert: I understand that your setup is a little different from what most people envision. You actually have the laser in your cataract surgery operating room (OR), and you do the procedure and just swivel the bed over and do the rest of the surgery?

Dr. Dick: Yes. This is the biggest advantage, and it was a good thing that I decided to place it in the OR because it allows us to do corneal incisions as well. In Germany and most areas of Europe, you can only place these in the OR because you are opening the eye. With the liquid optic interface, you can swivel the patient under the laser and go back and forth. You can even dilate the pupil first and then go under the laser. This is a big advantage. I would strongly suggest that the patient is not moved, because if the patient is moved to another OR, you are losing time. Currently, in a certain percentage of patients, the pupil goes down; it is rare, but it may come down and that is something you don’t want in a premium IOL, for example. This doesn't occur if the patient is directly operated on and then IOL is performed in the same place.

Dr. Steinert: Bill, what is your workflow going to be?

William B. Trattler, MD: We are going to copy exactly what you are doing, Dr. Dick. It makes so much sense. We are going to be putting the femtosecond laser in our OR and perform the laser and then swivel them over and do the cataract surgery immediately. We have a 5-room ambulatory surgery center in Miami, Florida. We don't have a separate room to put a femtosecond laser in, so it makes the most sense for us to do it in the same OR.

Dr. Steinert: We are in the process of completing construction of a whole new eye institute. I had great foresight and constructed a room next to the 2 ORs especially for the laser, and now you are making me think that I wasted space, so we will have to see. We are going to have to rethink all of that because we have been joking that in a university setting, the turnover is so slow that doing it in another room won't slow us down a bit -- but time will tell.

Dr. Dick: It doesn’t slow down your procedure. I am jumping between ORs so that means that I do about 3500 cataracts and about 1000 vitrectomies per year. You have to jump from one room to the next. It doesn't slow you down at all, and this has been shown with hundreds of patients already.

Dr. Steinert: Have your staff been able to keep track of which patients you want in the laser room and which cases you are going to do without the laser, and not get confused and have the patient in the wrong place?

Dr. Dick: We have an OR schedule, showing who is going to operate the femto, but you can do any patient with femto laser treatment. Of our 1200 cases, there were only 2 that we weren't able to treat, and those were patients with severe ankylosis who weren't able to fit on the table.

Dr. Trattler: With your high volume, do you envision having femto in both OR rooms?

Dr. Dick: I am thinking about buying a second laser, yes.

Dr. Trattler: It makes sense because the volume keeps going up.

Dr. Dick: Definitely. Femto is all we will do for the second eye procedure.

Better Vision in the First Week?

Dr. Steinert: You mentioned that patients are perceiving better results. Can you expand on that? The joke is that laser is a solution looking for a problem, so how is this making things better?

Dr. Dick: The cataract patients do not know how great the results will be, so it is hard for them to differentiate. Last week I was operating on a Lufthansa pilot who was 0.8 but already had a cataract that required surgery because of legal issues. Of course, that raised the bar very high and I was happy to have the femtosecond laser there. He turned out pretty well.

The great advantage, of course, is for the dense cataracts, where you have the prechop done already and the lens is already fragmented and corneal guttata forms in the eyes. The difficult cases definitely profit from this procedure. In a prospective randomized comparative trial, we have seen that in individual comparison, the femto eye was better by 1 line than the standard eye within the first week and then the difference dissipated.

Dr. Steinert: Why would vision be better in the first week?

Dr. Dick: Because there are fewer corneal folds and less corneal edema. In the last 100 cases I did, after changing the instrumentation setting, software, and so forth, 87 of those 100 patients did not need phaco at all, so as we switch out phaco and just aspirate it, this makes a big difference. If you do not apply phaco and do fewer manipulations in the eye, there is less inflammation. Inflammation was significantly lower in the femto group compared with the standard group.

Dr. Steinert: Your series, as well as others that are starting to come out, are showing less total ultrasound time. That should be an advantage as well. Have you had a chance to look at endothelial cell counts?

Dr. Dick: It is too early. Currently we have the 3-month data out. This study is powered for best-corrected visual acuity. We have a second prospective randomized trial, but we do not have the 3-month data yet. It is too early to conclude on that point, but I can tell you this: I recently had a patient with corneal guttata; the left eye was already operated outside and had a corneal decompensation graft on it; irregular astigmatism and visual acuity 0.03 P. She feared that her other eye would be the same. I operated on her with the femto treatment; she didn't need phaco at all, and the cornea was crystal clear. The referring doctor said to me, "Don't do femto treatment on my patients." I decided to do a femto case, and she turned out extremely well. This doctor now sends me his patients, who are already primed for femto.

Dr. Steinert: So you didn’t lose him as a referral?

Dr. Dick: No. Just the opposite.

Dr. Trattler: With femto being the way it is, are you able to use a less expensive viscoelastic? With phaco there was a lot of energy and we wanted to have viscoelastic there to protect the endothelium. Now it seems to be less of an issue, so I was wondering if you changed your viscoelastic or thought about changing it.

Dr. Dick: We will get rid of the ophthalmic viscoelastic device (OVD), because with the femto procedure I see no need for OVD any longer. We are also running a prospective trial comparing standard vs femto -- one eye with OVD with phaco, the standard case, and the femto without, because for the capsulotomy you don't need OVD. For irrigation and aspiration only, you definitely do not need OVD. It is needed only for lens implantation, but lens implantation can be done if you have one-handed, preloaded IOL with irrigation through the side port, and you don't need OVD. And that means no increase in intraocular pressure and other issues.

The Places We Will Go

Dr. Steinert: Bill, how do you see this ultimately affecting practice? Is this going to take us to places where we haven't been?

Dr. Trattler: Absolutely, because of the good outcomes. When I look at my patients on postoperative day 1, some patients are seeing 20/20 or 20/25 and they are very happy. Some patients who were a little more difficult to phaco and have corneal edema are seeing 20/50 or 20/60; they are a little bit less excited on postoperative day 1, and I have to reassure them that they will get better. If I could consistently get 20/20 or 20/25 on postoperative day 1 with femto, I think it would have a big impact on my patients. They have such high expectations going in, and the quicker I can get them to see, the better, so in the long term, we are going to see this totally taking over cataract surgery. I don't think there is any question about that.

Right now as refractive surgeons, we have the IntraLase™ (Abbott Medical Products; Abbott Park, Illinois), a femtosecond laser for making a flap, and an excimer laser; the total annual number of procedures in the United States is approximately 800,000. Now we are talking about cataract surgery, which represents 3.4 million patients yearly just in the United States. Numbers-wise, even though there is a cost for the femto, the volume will make it less expensive per case. Cost will be less of an issue going forward.

Dr. Steinert: Is it going to have an impact on IOLs and where we go with them?

Dr. Dick: Yes, definitely. It will totally change anything we have thought about. New things will come up -- maybe clipping or moving the lens into the intracapsule, the capsulotomy, or the post-capsulotomy. We can do a post-capsulotomy reliably with the laser, keeping the vitreous intact. It will definitely have a big impact on localization because with adequate biomorphologic detection, we will be able to place it exactly on the line of sight, which will definitely have an impact on the functionality of premium IOLs, like toric multifocal IOLs, if we place them better than we were able to before.

Dr. Steinert: I find it hard to believe that this won't, in the end, turn into one of those disruptive technologies that is very hard to imagine -- sitting here today -- any more than anyone foresaw that the first desktop computers would take us to where we are today; or that cell phones, when they were bag phones, would turn into smart phones that are mini-computers. It is hard to believe that this isn't going to ultimately take us to the land that we want to get to, which is the land of truly accommodating IOLs.

Dr. Trattler: With some of the imaging technologies for the various companies, you can see the entire bag, and it makes sense that right now one of the biggest challenges is to figure out the effective lens position of an IOL. Your idea of clipping the IOL to the bag makes a lot of sense, but even with our current technology, if we could guess where the lens would sit -- because we can image the bag well -- we might be able to do a better job of picking the right IOLs for each patient just during the imaging process of the femtosecond procedure.

Intrastromal Astigmatic Keratotomy

Dr. Steinert: Before we wrap up, let's talk about astigmatism. One of the things a laser can do that we can't do any other way is intrastromal astigmatic keratotomy (AK). I am hearing that many surgeons feel the same way, that the very low-power toric lenses aren't delivering the same kind of reliable correction that we are getting from the higher-powered lenses. Maybe this is going to be a particular niche, to do intrastromal AKs or the other version, even if they penetrate -- not necessarily opening them completely and being able to titrate it postoperatively by breaking down the little tissue bridges at the slit lamp. Do you have any thoughts on that or experience with that?

Dr. Trattler: I have been using the IntraLase and doing the intrastromal AKs, and it has actually worked very nicely. I have been treating patients at 1-2 diopters of astigmatism, and the pre- and postoperative topographies are very nice. These are patients who were scheduled for cataract surgery, and I decided to do the AKs before cataract surgery to first reduce the astigmatism, and so I could understand how it works. My initial results have been very positive so I am excited to do more.

Dr. Dick: The intrastromal is not capable of treating to that high extent. In my hands, it is approximately a 0.075 surgically induced change, but with high-precision, high-resolution optical coherence tomography, I am able to make a perfect cut. Fortunately we had the chance in a human eye to see whether it was true how precisely we are doing this. The patient had a malignant tumor and wanted the eye out, so we had the chance to perform laser first on a real human eye and do the histopathology on it, and we were deeply impressed. It was exactly 200 microns left from the endothelium, cut at exactly 30 degrees, and then cut precisely through the Bowman layer exactly as we wanted it to, and the epithelium was kept intact. This is really an impressive technology and I am sure that this will improve our outcomes.

Dr. Steinert: I would like to thank our guests, Dr. William Trattler and Dr. Burkhard Dick, for taking time out from their very busy Academy and sharing their insights, thoughts, and experiences with us. Thanks to the audience for joining us. I'm Dr. Roger Steinert for Medscape Ophthalmology.