COMMENTARY

Out With the Old, in With the New: The Best of AAO 2013

American Academy of Ophthalmology 2013

Roger F. Steinert, MD; Eric D. Donnenfeld, MD; Richard A. Lewis, MD

Disclosures

November 25, 2013

In This Article

That Newfangled Femto Is the Future

Dr. Steinert: I remember being at the Academy in Orlando just a couple of years ago, and there was raging debate about the femtosecond laser for cataract surgery. Most ophthalmologists at that point thought that this was completely bogus and unnecessary -- a fool's errand, etc. Fast-forward to New Orleans in 2013. Where are we with the femtosecond?

Dr. Donnenfeld: It has been an interesting ride. Three years ago, the femtosecond laser for cataract surgery did not exist. The first commercial units came in 2.5 years ago. At that time, patients were being asked to use this new technology, and doctors were debating whether this technology is better. Is it a good thing to offer to our patients?

Now we have seen literally dozens of studies, many of them presented right here at the AAO, that show that with the use of femtosecond laser surgery, we can reduce phacoemulsification (phaco) time. A study by Burkhard Dick[3] showed that in his surgical hands, there is no phaco time. It's just an aspiration device after the laser has turned the lens into little cubicles. So we are reducing our phaco time. There is less inflammation, less endothelial cell loss, less corneal edema, and less risk for posterior capsule tears. These patients are having less traumatic surgery and they are getting better refractory results, maybe because of the better effective lens position, but certainly because we have reproducible and precise limbal relaxing incisions. For the 80% of ophthalmologists who never perform limbal-relaxing incisions, they can now do this with certainty because of a digital technology that gives them the efficacy of the most advanced surgeon.

Femtosecond laser surgery, in my estimation, is here to stay. The future is going to be unbelievable. We are only 3 years into it right now. Three or 4 years from now, I predict that almost every cataract surgery will be done with almost no phacoemulsification because of the ability of this device to improve cataract surgery technique.

Dr. Steinert: It's interesting. I have always felt that our problem was that we weren't able to look far enough into the future, just the way phaco didn't seem to make a whole lot of sense until foldable lenses came along, except foldable lenses only came along because of phaco. We will ultimately have the same situation here. Femtosecond lasers for cataract surgery are going to enable things that we were having a hard time imagining.

We have already heard about the first generation of femtosecond laser intraocular lenses (IOL), with a little rim in the front. Because the capsulotomy is perfectly round and perfectly sized, you can pop that in and have the IOL absolutely fixated. You never doubt where it was going to be postoperatively. It will probably be a while before you see that in the United States, but the Europeans certainly are starting to talk about that.

Dr. Donnenfeld: All the major companies who make IOLs are now looking at different lens designs because they have the reproducibility and precision of a digitally engineered capsulotomy and the ability to make smaller and smaller incisions. I predict that our lens designs will be vastly different several years from now because of our ability to do cataract surgery in a different way

Dr. Lewis: Many surgeons are trying to resist this move to the femto, with the argument that their capsulotomies are perfect, they don't have complications, and they don't tear capsules. The argument is so similar to the argument that we heard when the conversion went from extracap to phaco, that there is that resistance to jump into this technology. You can't stop this. This is clearly taking over. This is the way all cataract surgery will be done. It makes all of us better surgeons, but it definitely makes the average surgeon a better surgeon too.

Dr. Donnenfeld: It's good for ophthalmology, and most important, it's good for patients.

Dr. Steinert: During the refractive subspecialty day, the audience was asked whether they were thinking about getting a femtosecond laser in the near future, were already using one, or don't think they are going to do it. I was shocked. If I remember the numbers, 45% of that audience is already using femtosecond laser for cataract surgery. That's a skewed group. It doesn't represent all of ophthalmology, to be sure. I didn't think that number would be remotely that high.

Dr. Lewis: They have really marketed it; the companies have pushed hard. The number of placements of femto lasers is amazing. Everyone recognizes that, and the patients are demanding it. Patients come to my office and want the femto. The only question is whether they can afford it. It isn't a question of whether they want this procedure. It's an exciting time for cataract surgery.

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