Femtosecond Laser Cataract Surgery- Magic or Myth? A Balanced View

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Femtosecond lasers are being touted as the next great leap forward in cataract surgery but, as with any radical change to our practices, many questions remain: Does this technology truly improve cataract surgery? Is the refractive accuracy better? Is the safety profile significantly elevated compared to existing technologies? Are there additional complications or issues with using this laser?

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Femtosecond Laser Cataract Surgery- Magic or Myth? A Balanced View

  1. 1. Eastwood Eye Surgery Dr Gagan Khannah Ophthalmic Surgeon Eastwood Eye Surgery Macquarie University Hospital Sydney Eye Hospital PresMed Annual Optometrist Conference 10th March 2013 Femtosecond Laser Cataract Surgery – Magic or Myth? A Balanced View!
  2. 2. Laser Assisted Cataract Surgery
  3. 3. • Individual steps of laser assisted cataract 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 impression Agenda
  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 or meaningful • Are the benefits clinically or practically significant • Is the benefit worth the extra time, cost and effort Assessing evidence for new technology
  6. 6. • High resolution anterior segment imaging coupled to femtosecond laser • Anterior capsulotomy • Nuclear fragmentation • Corneal incisions (primary, secondary and arcuate incisions) Capabilities of LenSx laser
  7. 7. Anterior Capsulotomy
  8. 8. • Perform capsulotomy safely and completely, resistant to tearing • Central, circular and reproducible – anteroposterior effective lens position – lateral centration – IOL calculations • Predictably overlap IOL edge by 0.5mm Anterior Capsulotomy
  9. 9. Anterior Capsulotomy • Most striking feature of day 1 appearance • Published evidence?
  10. 10. Anterior Capsulotomy • Nagy – 100% of anterior capsulotomies within 0.25mm vs 10% of manual
  11. 11. Anterior Capsulotomy • Tackman, Fried man – less deviation from intended diameter – increased circularity
  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 power and protection of corneal endothelium Femtosecond nuclear fragmentation
  15. 15. • No reports of femtosecond laser direct damage to posterior capsule • Offset from posterior capsule on imaging appears to be effective in preventing this Nuclear fragmentation - safety
  16. 16. • Reducing need to go deeper with phaco tip may reduce risk of PC rupture • 0.31% PC rupture rate lower than reported incidence of 0.53% - 2.7% in manual surgery Nuclear fragmentation - safety
  17. 17. • Decreased total phaco energy confirmed to statistically significant level in multiple studies • Close to 50% reduction in both total phaco energy and phaco time • May reduce damage to corneal endothelium • May reduce potential for inflammation and corneal burns Nuclear fragmentation - safety
  18. 18. • Statistically significant reduction in phaco energy in all grades of cataract • No studies yet to confirm reduction in endothelial cell loss. Further long term studies required. • May be particularly important in patients with Fuch’s dystrophy • Younger patients Endothelial protection
  19. 19. Corneal incisions
  20. 20. Ability to customise reproducible, m ultiplanar corneal wounds shown in multiple studies Corneal incisions
  21. 21. • Reproducible wounds may allow more consistent surgically induced astigmatism • No large studies published at this stage Corneal incisions
  22. 22. • Endophthalmitis a rare but devastating complication • Well constructed clear corneal wounds may reduce the risk of endophthalmitis • Difficult to study: incidence 0.13% • A lot of data would be required to prove a benefit in reducing endophthalmitis Corneal incisions
  23. 23. Latest Results
  24. 24. • In this section, focus on objective current data, not on our clinical impression • Objective data already demonstrates that LACS is no worse than manual phaco – Short learning curve – Would not have been able to say this about move from ECCE to phaco in first 12 months – Took until 2001 for first large scale RCT proving cost effectiveness of phaco vs ECCE Conclusions
  25. 25. • New technology – experience rising very rapidly – 30,000 cases, almost all in the last 12 months • Data demonstrating statistically significant benefit in a number of areas – at this stage relatively little definite clinically significant data – large number of studies currently underway – longer term studies, eg endothelial cell loss Conclusions
  26. 26. • Positive initial impressions, not discouraged by: – inability to immediately have clinically significant evidence base – new complications – increases in cost • As technology and techniques mature, history suggests: – complications decrease – equipment costs reduce with widespread adoption – outcomes and efficiencies improve – Other technologies develop Conclusions
  27. 27. Eastwood Eye Surgery Laser Refractive Cataract Surgery Provides Image – guided, surgeon control to perform: – Anterior capsulotomy – Lens fragmentation – Corneal incisions 4 systems currently in development
  28. 28. Eastwood Eye Surgery Laser Refractive Cataract Surgery Possible Advantages – Automates steps of cataract surgery – Improved corneal incisions & astigmatism control – Improved capsulotomy for effective lens positioning – Less phaco energy and endothelial cell loss
  29. 29. Eastwood Eye Surgery Laser Refractive Cataract Surgery Disadvantages – Topical anaesthesia – Cost – Limitations Small pupil Corneal opacity Dense cataract Keratoconus
  30. 30. Eastwood Eye Surgery Laser Refractive Cataract Surgery Exciting technology and future is bright Still in its infancy and benefits unclear Requires better safety data & research Costs must be addressed Secondary advances may revolutionise cataract surgery
  31. 31. Thank You

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