Femtosecond Laser Cataract Surgery – Magic or Myth?


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Dr Gagan Khannah
Ophthalmic Surgeon
Eastwood Eye Surgery
Macquarie University Hospital
Sydney Eye Hospital

PresMed Annual Optometrist Conference
10th March 2013


Published in: Health & Medicine
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Femtosecond Laser Cataract Surgery – Magic or Myth?

  1. 1. EastwoodEye SurgeryDr Gagan KhannahOphthalmic SurgeonEastwood Eye SurgeryMacquarie University HospitalSydney Eye HospitalPresMed Annual Optometrist Conference10th March 2013Femtosecond Laser CataractSurgery – Magic or Myth?A Balanced View!
  2. 2. Laser AssistedCataract Surgery
  3. 3. • Individual steps of laser assistedcataract surgery (LACS)– Anterior capsulotomy– Nuclear fragmentation– Corneal incisions• Hypothetical benefits• Discuss the current evidence base– very early days in adoption of LACS– further discussion of clinical impressionAgenda
  4. 4. Does LACS:• Improve precision and reproducibility?• Improve safety?• Improve refractive outcomes?Questions
  5. 5. • Are the benefits statistically significant:– Result unlikely to occur by chance– Does not mean result is important ormeaningful• Are the benefits clinically or practicallysignificant• Is the benefit worth the extra time, costand effortAssessing evidence for newtechnology
  6. 6. • High resolution anterior segmentimaging coupled to femtosecond laser• Anterior capsulotomy• Nuclear fragmentation• Corneal incisions (primary, secondaryand arcuate incisions)Capabilities of LenSx laser
  7. 7. Anterior Capsulotomy
  8. 8. • Perform capsulotomy safely andcompletely, resistant to tearing• Central, circular and reproducible– anteroposterior effective lens position– lateral centration– IOL calculations• Predictably overlap IOL edge by 0.5mmAnterior Capsulotomy
  9. 9. Anterior Capsulotomy• Most striking feature of day 1 appearance• Published evidence?
  10. 10. Anterior Capsulotomy• Nagy– 100% ofanteriorcapsulotomieswithin 0.25mmvs 10% ofmanual
  11. 11. Anterior Capsulotomy• Tackman,Friedman– less deviationfrom intendeddiameter– increasedcircularity
  12. 12. Anterior Capsulotomy• Zoltan Nagy– Series of studies– Less IOL tilt and decentration– Better IOL-anterior capsule overlap– Decreased higher order aberrations• Clinical significance?– No definite improved refractive result (sphere,cylinder or unaided visual acuity)– Longer term studies required– Subgroup analysis required
  13. 13. Nuclear Fragmentation
  14. 14. • Effectively disassemble the nucleus• Safety: protection of posterior capsule• Safety: reduction in total phaco powerand protection of corneal endotheliumFemtosecond nuclearfragmentation
  15. 15. • No reports of femtosecond laser directdamage to posterior capsule• Offset from posterior capsule on imagingappears to be effective in preventing thisNuclear fragmentation- safety
  16. 16. • Reducing need to go deeper with phaco tipmay reduce risk of PC rupture• 0.31% PC rupture rate lower than reportedincidence of 0.53% - 2.7% in manual surgeryNuclear fragmentation- safety
  17. 17. • Decreased total phaco energy confirmed tostatistically significant level in multiple studies• Close to 50% reduction in both total phacoenergy and phaco time• May reduce damage tocorneal endothelium• May reduce potential forinflammation andcorneal burnsNuclear fragmentation- safety
  18. 18. • Statistically significant reduction in phacoenergy in all grades of cataract• No studies yet to confirm reduction inendothelial cell loss. Further long term studiesrequired.• May be particularly important in patients withFuch’s dystrophy• Younger patientsEndothelial protection
  19. 19. Corneal incisions
  20. 20. Ability tocustomisereproducible,multiplanarcorneal woundsshown inmultiple studiesCorneal incisions
  21. 21. • Reproduciblewounds may allowmore consistentsurgically inducedastigmatism• No large studiespublishedat this stageCorneal incisions
  22. 22. • Endophthalmitis a rare but devastatingcomplication• Well constructed clear corneal wounds mayreduce the risk of endophthalmitis• Difficult to study: incidence 0.13%• A lot of data would be required to prove abenefit in reducing endophthalmitisCorneal incisions
  23. 23. Latest Results
  24. 24. • In this section, focus on objective currentdata, not on our clinical impression• Objective data already demonstratesthat LACS is no worse than manualphaco– Short learning curve– Would not have been able to say this about movefrom ECCE to phaco in first 12 months– Took until 2001 for first large scale RCT provingcost effectiveness of phaco vs ECCEConclusions
  25. 25. • New technology– experience rising very rapidly– 30,000 cases, almost all in the last 12 months• Data demonstrating statistically significantbenefit in a number of areas– at this stage relatively little definite clinicallysignificant data– large number of studies currently underway– longer term studies, eg endothelial cell lossConclusions
  26. 26. • Positive initial impressions, notdiscouraged by:– inability to immediately have clinically significantevidence base– new complications– increases in cost• As technology and techniques mature, historysuggests:– complications decrease– equipment costs reduce with widespread adoption– outcomes and efficiencies improve– Other technologies developConclusions
  27. 27. EastwoodEye SurgeryLaser Refractive CataractSurgeryProvides Image –guided, surgeoncontrol to perform:– Anterior capsulotomy– Lens fragmentation– Corneal incisions4 systems currently indevelopment
  28. 28. EastwoodEye SurgeryLaser Refractive CataractSurgeryPossible Advantages– Automates steps of cataract surgery– Improved corneal incisions & astigmatismcontrol– Improved capsulotomy for effective lenspositioning– Less phaco energy and endothelial cell loss
  29. 29. EastwoodEye SurgeryLaser Refractive CataractSurgeryDisadvantages– Topical anaesthesia– Cost– LimitationsSmall pupilCorneal opacityDense cataractKeratoconus
  30. 30. EastwoodEye SurgeryLaser Refractive CataractSurgeryExciting technology and future is brightStill in its infancy and benefits unclearRequires better safety data & researchCosts must be addressedSecondary advances may revolutionisecataract surgery
  31. 31. Thank You