Linda Roach

May 24, 2013

SAN FRANCISCO, California — How much of today's phacoemulsification-based cataract surgery will someday be replaced with femtosecond laser surgery?

After several years of being largely theoretical, clinical evidence that the femtosecond laser has advantages over conventional cataract surgery is beginning to accumulate. This was apparent in research papers, panel discussions, and other events here at the American Society of Cataract and Refractive Surgery 2013 Symposium.

In one session, experts examined the role of the femtosecond laser in cataract surgery.

Jonathan Talamo, MD, a refractive, cataract, and corneal surgeon from Boston, Massachusetts, told several hundred ophthalmologists that they are witnessing "the end of the beginning" of the story of femtosecond laser-assisted cataract surgery.

"I can tell you this from my very core: This is the future of ophthalmology," agreed Kerry Solomon, MD, a cataract and refractive surgeon from Charleston, South Carolina.

Robert Rivera, MD, a refractive surgeon from Draper, Utah, echoed these sentiments. "Say goodbye to phacoemulsification. We are now calling this femtoemulsification," Dr. Rivera said. He noted that prefragmenting the lens with the Catalys laser (OptiMedica) has enabled him to use at least 66% less phaco power to disassemble the lens, and in some cases 90% less.

But Stephen Slade, MD, a refractive and cataract surgeon from Houston, Texas, cautioned that a goal of using zero phaco power 100% of the time might require tradeoffs with unintended consequences. For instance, if zero phaco power lengthened cataract surgery, the risk of harming the corneal endothelium also would increase, he said.

 
I can tell you this from my very core: This is the future of ophthalmology.
 

"I'm just not sure if it should be a goal to eliminate one technology and end up with a lower endothelial cell count. I can get 1000 miles per gallon in my car if I push it to work. But I just don't see that there's anything wrong with tapping that foot pedal," Dr. Slade said.

Speakers credited the laser with, among other things, reducing the amount of ultrasound energy delivered to the eye during phaco, causing less postoperative corneal edema, facilitating the bag-in-the-lens implant technique, making 4+ lenses behave more like a 2+ lenses during removal, and making corneal incisions and the capsulorhexis more predictable.

For instance, Barry Seibel, MD, a cataract surgeon from Los Angeles, California, and colleagues report that by reducing the distance between laser spots in the grid pattern used to prefragment the lens before phacoemulsification, the effective phaco time was reduced 99% compared with manual lens disassembly with the Catalys laser.

Meanwhile, laser manufacturers have been trying to stay ahead of one another in the market by rolling out a steady stream of improvements to their laser hardware and software. Most notable is a new docking apparatus and software upgrade that industry-leading Alcon Laboratories released several months ago for its LenSx femtosecond laser.

Those modifications appear to have resolved 2 patient safety issues that occurred more frequently with the LenSx than with other lasers. The problems include extreme elevation of intraocular pressure from the suction and applanation apparatus that docked the eye to the laser and a 10.5% reported incidence of capsular tags, which can lead to a torn capsule.

More than 200 LenSx femtosecond lasers are in place around the world, and they have been used in more than 50,000 cataract surgeries.

Dr. Talamo reports being a consultant for several ophthalmic companies, including OptiMedica, Abbott Medical Optics (AMO), and Bausch + Lomb; and receiving research funding from AMO, Bausch + Lomb, Nexis Vision, and Ocular Therapeutix. Dr. Solomon reports being a consultant for AMO, Alcon, Bausch + Lomb, and several other companies; and receiving research funding from AMO, Alcon, Allergan, Nidek, and Zeiss. Dr. Rivera reports being a member of the speakers' bureau for Alcon, OptiMedica, AcuFocus, and EndoOptiks; and receiving research funding from Avedro and Sonomed. Dr. Slade reports being a consultant for Alcon, NuLens, and Technolas; and having equity interest in Bausch + Lomb and ReVision Optics. Dr. Seibel reports being a consultant to OptiMedica and receiving royalties from Bausch + Lomb and Rhein Medical.

American Society of Cataract and Refractive Surgery (ASCRS) 2013 Symposium: Paper session 2-A. Presented April 21, 2013.

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