Eastwood

Eye Surgery

Femtosecond Laser Cataract

Surgery – Magic or Myth?
A Balanced View!
Dr Gagan Khannah
Ophthalmic Surgeon
Eastwood Eye Surgery
Macquarie University Hospital
Sydney Eye Hospital
PresMed Annual Optometrist Conference
10th March 2013
 Laser Assisted
Cataract Surgery
 Agenda

• 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
 Questions

Does LACS:
• Improve precision and reproducibility?
• Improve safety?
• Improve refractive outcomes?
Assessing evidence for new
technology

• 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
 Capabilities of LenSx laser

• High resolution anterior segment

imaging coupled to femtosecond laser

• Anterior capsulotomy

• Nuclear fragmentation

• Corneal incisions (primary, secondary

and arcuate incisions)
Anterior Capsulotomy
 Anterior Capsulotomy

• 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

• Most striking feature of day 1 appearance

• Published evidence?
 Anterior Capsulotomy

• Nagy

– 100% of
anterior
capsulotomies
within 0.25mm
vs 10% of
manual
 Anterior Capsulotomy

• Tackman, Fried
man
– less deviation
from intended
diameter

– increased
circularity
 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
Nuclear Fragmentation
 Femtosecond nuclear
fragmentation

• Effectively disassemble the nucleus

• Safety: protection of posterior capsule

• Safety: reduction in total phaco power

and protection of corneal endothelium
 Nuclear fragmentation
- safety

• 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

• 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
• 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
 Endothelial protection

• 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
Corneal incisions
Corneal incisions

Ability to
customise
reproducible, m
ultiplanar
corneal wounds
shown in
multiple studies
 Corneal incisions

• Reproducible
wounds may allow
more consistent
surgically induced
astigmatism

• No large studies
published
at this stage
 Corneal incisions

• 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
Latest Results
 Conclusions

• 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

• 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

• 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
 Laser Refractive Cataract
Surgery Eastwood
Eye Surgery

Provides Image –
guided, surgeon
control to perform:
– Anterior capsulotomy
– Lens fragmentation
– Corneal incisions
4 systems currently in
development
 Laser Refractive Cataract
Surgery Eastwood
Eye 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
 Laser Refractive Cataract
Surgery Eastwood
Eye Surgery

Disadvantages
– Topical anaesthesia
– Cost
– Limitations
Small pupil
Corneal opacity
Dense cataract
Keratoconus
 Laser Refractive Cataract
Surgery Eastwood
Eye 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
Thank You