Femtosecond Laser Cataract Surgery in the United States.
In February 2010, my staff and I received the LenSx femtosecond laser (LenSx Lasers Inc., Aliso Viejo, CA; distributed in the United States by Alcon Laboratories, Inc., Fort Worth, TX). Since then, we have been successfully performing laser cataract surgery at our center in Huston. I believe this technology represents the perfect marriage of the cataract and refractive subspecialties. This article describes what I foresee as the femtocataract technology’s position in ophthalmology.
MEETING PATIENT DEMANDS
Each year, there are approximately 3.25 million cataract surgeries performed in the United States and around 19 million procedures worldwide. Are we delivering the level of care that patients desire with cataract surgery? Refractive surgery taught me that patients need two things to be happy: a safe surgery, and the ability to see well without glasses afterwards. Even individuals who need a complicated procedure such as a corneal transplant or riboflavin/UV cross-linking ultimately want to see perfectly without their glasses. Are we surgeons delivering on that request?
Figure X shows the 20/25 and 20/20 UCVA results from the latest FDA trial on an IOL compared with the latest FDA data on LASIK. There is a wide difference between these two procedures. It appears as though we are not giving our cataract patients the kind of UCVA that we are providing LASIK patients. Can we correct this problem?
Market Scope approximates that there are 6,800 cataract surgeons in the United States. Only 2,000 of those practitioners identify themselves as cataract/refractive surgeons. The rest consider themselves either cataract surgeons who do not perform refractive surgery or refractive surgeons who perform very few cataract surgeries. Therefore, the small group of cataract/refractive surgeons has the best chance to address the disparity between the two subspecialties.
TIME AND PLACE: FITTING THE LENSX INTO THE CLINIC
We do not keep the LenSx laser in the OR, but in a separate, environment-controlled room. Both my staff and my patients appreciate the speed of the laser. The LenSx requires about 60 seconds of suction time, and it takes another 3 to 5 minutes to make the capsulotomy and fragment the nucleus. Then, we roll the patient into the OR to extract the nucleus and implant the lens. This laser cuts the length of a cataract procedure in half.
The laser’s proprietary optical coherence tomography (OCT) imaging system lets you view the entire anterior segment as you operate the machine. The laser begins the cut for the capsulorhexis posteriorly, then it penetrates into the anterior chamber to fracture the nucleus. It leaves a beautiful, 3-dimensional (3-D) cut in the nucleus. The LenSx can also make secondary and astigmatic cuts in the cornea. In fact, the laser features a laser “knife” that you can preprogram to make 10 to 12 different types of cuts—cylinders, slits—the sky is the limit.
SURGICAL ADVANTAGES OF THE LENSX LASER
The LenSx femtosecond laser can help us improve the quality of cataract surgery two ways. First, the laser enables the surgeon to precisely control the capsulotomy. The human hand cannot make capsulotomies as perfectly shaped or reproducible as a femtosecond laser. The laser also provides amazing control over the capsulotomy’s centration, shape, and diameter, and you can achieve the exact same configuration every time. As all cataract surgeons know, the capsule’s opening is very important in determining the effective lens position. A smaller opening will induce more contraction, and a larger opening will result in the opposite. We can measure the corneal curvature and the axial length, but we cannot predict the IOL’s final resting position. With the LenSx laser providing a consistent capsulorhexis, we can predict the effective lens position much more accurately. Just by switching to this device, I have reduced my standard deviation of spherical component considerably. Simply put, this laser makes lens implantation more predictable.
The LenSx femtosecond laser also improves the management and correction of astigmatism. What if we could make limbal relaxing incisions (LRIs) in the same way we treat astigmatism with an excimer laser? The LenSx has preprogrammed astigmatic cuts that make this procedure simple. It allows us to place LRIs wherever you wish. My staff and I use Eric Donnenfeld, MD’s nomogram with outstanding results.
Figure X shows the LenSx laser performing nuclear cracking. Colleagues have asked me how this procedure will impact phacoemulsification. I think it is the perfect partner for phacoemulsification, because it will allow us to optimize our phaco machines and our techniques. We can still use our preferred technique to remove the fragmented nucleus.
Another advantage I think this device offers is with removing cortex. We can start the capsulorhexis behind the capsule and then come up through it and bypass the cortex. This approach ensures that we get [polish?] the capsule. The cortex then has a soft-cut edge all the way around the capsulorhexis, which makes removing it a little bit easier and more efficient.
Again, with the ability to size and locate the capsulorhexis where we want it, we should be able to customize this step to individual IOLs in the future. Perhaps certain implants will be centered anatomically, by line-of-sight, or on the dilated pupil. Because the LenSx laser can standardize these steps, we can track our results with various techniques. All of these capabilities will drive effectiveness in cataract surgery.
The femtocataract procedure also has exciting implications for challenging eyes, such as those with low endothelial cell counts, pseudoexfoliation, etc. I’d rather leave the zonules alone in those patients. A femtosecond-made capsulotomy on an eye with a white cataract will not require capsular dye.
SAFETY
The literature shows that refractive surgery is safer than cataract surgery, with fewer incidences of adverse events. I think the LenSx femtosecond laser can improve surgical safety and efficacy. Since using this machine, my staff and I have seen a dramatic reduction in phaco time, phaco power, and endothelial cell loss compared with the historical norm that we found in literature. These findings make sense, because the femtocataract procedure reduces phacoemulsification and the number of times the surgeon enters the eye.
For now, my staff and I are concentrating on optimizing our cataract surgeries using the INFINITI Vision System with AquaLase, OZil IP torsional ultrasound (Alcon Laboratories, Inc., Fort Worth, TX), and different tips and settings. We are exploring how to adapt these technologies to use them together. For example, for soft nuclei, we can use a series of soft cylinders to liquefy the cataract and then perform I/A. In the majority of cases, we use a blend of femtosecond laser and phacoemulsification to improve our speed, safety, and outcomes.
CONCLUSIONS
I think the femtocataract procedure will bring us the efficacy and safety we want for our patients. In the coming years, the baby boomers—the biggest demographic group in the United States—will be moving into their cataract years. These individuals will make up the majority of our patients. The femtocataract technology will suit this demographic beautifully; I anticipate that baby boomers will readily adopt a more automated cataract surgery just like they have accepted all-laser LASIK. I suggest that we all get ahead of this curve.
Stephen G. Slade, MD, is a surgeon at Slade and Baker Vision in Houston. He serves as the medical director for LenSx Lasers Inc., and he is a consultant for Alcon Laboratories, Inc.
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