Refractive Surgery: Technology on Trial

Femtosecond Laser Cataract Surgery: Pro or Con?

Hello. I'm Dr Roger Steinert, chair of ophthalmology and director of the Gavin Herbert Eye Institute at the University of California, Irvine. This is the first of several video blogs that I will be doing about the annual meeting of the American Academy of Ophthalmology (AAO) being held now in Chicago.

I had the opportunity to come in early for the two-day refractive subspecialty sessions. On Friday, one of the highlights was a very interactive session on the issue of femtosecond laser cataract surgery. It was structured as a point-counterpoint session, with audience and panel discussions about the presentations. There was a "pro" presenter and a "con" presenter on each of the issues of efficacy, safety, and cost. I compliment these presenters for the work that they put into the presentations, which were very detailed as well as humorous and informative.

There was no consensus among the three expert panelists: One felt strongly in favor of femtosecond cataract surgery; one was on the fence; and one felt that the time had not yet come. These opinions seemed to be largely formed by the experiences of the panelists prior to the sessions and the decisions they had made in their own practices.

However, results of polling the audience were quite different. From the audience poll and their reactions to the presentations, it was clear that most of the audience members (at least 1000 people) do not yet feel compelled to purchase a femtosecond laser cataract unit nor do they feel that they need it. They seem to feel that, with a few exceptions, it would be not cost-effective, especially given the reimbursement structure in the United States, in which only the refractive component can be billed for.

The Word on the Street

I did some "on the street" polling of my own. It seemed evident that for the surgeons who had made the commitment and have access to a femtosecond laser cataract unit, they use the unit and they like it. This includes a surgeon who is in a surgery center where she does not have any personal financial exposure or requirement and could use it or not use it. She really likes it and uses the femtosecond laser cataract unit on a regular basis. I think the jury is still out on this issue.

My view is that it is a very interesting technology. It's a lot of fun to use. The tipping point on this is going to be the development of interactive lenses that are enabled by this technology and perhaps could only be used with this technology. That happened with the transition from extracap to phacoemulsification with the introduction of small-incision lenses. I believe that we will see this again, but it is going to take a little time because, as we know, the development and validation of interactive lenses does not happen quickly, particularly in the United States. We will presumably see these developments sooner out of Europe.

Toric IOLs on Trial

On Saturday there was a great session, structured as a trial with a judge and a jury, on the hot-button issue of astigmatism correction, and particularly toric intraocular lenses (IOLs). This was a very thorough and comprehensive session, starting with a keynote lecture by Doug Koch on the issue of the posterior corneal astigmatism and how we can better measure it, rather than just doing a standard nomogram adjustment in which you back down on with-the-rule astigmatism and add up on against-the-rule astigmatism. The problem is that there is a lot of scatter. On average, that is a true measurement, but there is variability from patient to patient.

The subsequent talks were about various methods of marking and intraoperative measurement at the end using wavefront aberrometry. The audience poll and the "judges" were strongly of the opinion that if you were just using one device, you would want the wavefront aberrometer.

Listening to the presentations, it was clear that people want several things. One is the ability to go into the operating room with a good idea of where that lens needs to sit and be oriented in a very precise and user-friendly way.

The two current commercial devices that accomplished this in a straightforward way are the VERION™ system from Alcon (Fort Worth, Texas) and the Callisto system from Carl Zeiss (Richmond, Virginia). Callisto just received US Food and Drug Administration approval to move to a completely markerless system that is integrated with the IOL master (making your workflow easier and shorter), and then marry that technology with an intraoperative measurement such as the WaveTec ORA System® (WaveTec; Aliso Viejo, California) or the not-yet-released (but in development) HOLOS system from Clarity Medical Systems (Pleasanton, California). This is still clearly an area that is in evolution.

The topography devices, particularly the Scheimpflug-type scanning or the tomography units, in principle, should be able to measure the posterior corneal astigmatism and give us true corneal power so that we are not just using an average nomogram. There was a lot of audience interest in and enthusiasm for these presentations, and they were quite informative and beneficial.

Toric IOLs and the correction of astigmatism are areas of major interest to surgeons. I had the opportunity to lead one of the “break with the experts” discussions for 50 minutes, and I thought that there might only be a handful of people at my table. Instead, people were lined up three deep, asking many terrific questions about toric IOL issues: how to get it right, and what to do when you are disappointed with the postoperative results.

I'm Dr Roger Steinert on behalf of Medscape. Thanks very much for listening.

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