There is no question, based on over 1 million procedures and a huge number of installations worldwide, that femtosecond lasers are here to stay. In spite of the huge capital cost and per-procedure price—a concept Europe is slowly accepting but one our US colleagues are already familiar with—the technology has penetrated widely. The naysayers were wrong and are eating humble pie, as many have now bought a femtosecond laser!

The arguments against femtosecond lasers (eg, how adoption might affect the bottom line, the relative slowness of the procedure, possibility of inflammation) seem to have fallen by the wayside, partially because many have been resolved by changes in speed and lower energy (ie, companies are paying attention to their users). Flap creation with the 60-KHz IntraLase FS laser (IntraLase Corp., Irvine, California) may now be as quick as 18 seconds, depending on spot separation and flap size. In this issue, Damien Gatinel, MD, PhD, introduces some interesting arguments both for and against adoption of the femtosecond laser. Emilio Balestrazzi, MD, and colleagues; and Suphi Taneri, MD, also offer their reasons for using or not using this technology. John Marshall, PhD, a long-time standing PRK/surface ablation diehard, now supports LASIK using the femtosecond laser, as long as thin flaps are created. Professor Marshall's rationale for this change is discussed in his article.

Although decisions about purchasing technology are often made with a level of emotion and may be frivolous, the sheer cost of femtosecond technology is enough to make one stop and think again. There does need to be a case to purchase, and I made the choice based on (1) safety and (2) the opportunity this new technology affords in innovation and new procedures, particularly in the arena of corneal transplantation.

My personal belief is that the question, "Is femtosecond technology the gold standard?" is now almost over. The technology is here to stay, and like any business: To survive, we as providers must give our patients what they want. As patients learn about this technology, it is something they desire. In the majority of cases, patients are happy to pay a premium.

It is a delight to see new femtosecond laser entrants in the market. As is the case with any competition, quality will improve and prices will decrease—if the new entrants wish to take up market share and adopt a sensible pricing strategy. It goes without saying that to be a serious competitor, the newer femtosecond lasers have to work and deliver at a level of reproducibility and reliability that is equal or superior to the current dominant player, IntraLase. Added advantages are secondary.

Primarily, lasers must be able to consistently and safely cut flaps at user-defined depths and dimensions, as this is the basis for paying the bills. In this issue, we learn about some of the newer femtosecond lasers. As this issue is a face-off, a certain level of defensiveness regarding each laser system is evident. It must be remembered that each system has its merits. As far as our intelligent readers will conclude, ultimately the truth will be told through published results and outcomes.

Femtosecond lenticular extraction (FLEx) is performed with the VisuMax system (Carl Zeiss Meditec AG, Jena, Germany). This refractive procedure sounds very interesting, and some anecdotal evidence has been described by Walter Sekundo, MD. The concept of a lenticular cut for refractive correction is not new. It was initially pursued by IntraLase—and probably still is. Based on preliminary reports, Carl Zeiss Meditec appears to have found a solution, and we are all keen to see the actual data in due course. The Femto LDV (Ziemer Ophthalmic Systems, Port, Switzerland) promises a level of portability that may suit the occasional user and could serve the roll-on/roll-off market.

IntraLase has put a lot of resources into the development of IntraLase enabled keratoplasty, and upgrades are presently being rolled out. Preliminary experience using this technology has been very promising and certainly exciting for those involved in corneal transplantation. The reproducibility of trephination and the ability to make a variety of geometrical cuts may alter the predictability of refractive and visual outcomes.

The IntraLase femtosecond laser, along with new entrants, is a welcomed addition to our ophthalmic armamentarium, however, current capital costs further raise the bar for ophthalmologists wishing to establish a refractive surgery facility. This issue alone will affect how practices ultimately evolve, and it will be interesting to see what takes place in the future. We at CRST Europe shall no doubt be revisiting femtosecond lasers as the technology evolves and new entrants make headway. Until then, I hope you enjoy this issue, which summarizes current status in April 2007.