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Up Front | Sep 2010

CHIEF MEDICAL EDITOR’S PAGE: Femtosecond Lasers are Past the Stage of Simply Making Flaps

During the advent of femtosecond lasers, I was not fully convinced that this technology would become a reliable alternative as a flap maker. For starters, I reasoned, the laser is significantly more costly and time consuming than use of mechanical keratomes. Then there is the issue of an associated learning curve. For many years I did not change my opinion, because the results with my mechanical device were so good and my complication rates so very low. However, once I began to use the femtosecond laser for myself, my tune quickly changed.

The Technolas 520F (Technolas Perfect Vision GmbH, Munich, Germany) was installed in my surgical center in October 2009. Initially, I only used it for the treatment of presbyopia with Intracor, but after a while I became interested in making flaps with it. And I have to admit that I am pleasantly surprised by the outstanding outcomes. Therefore, offering refractive surgery as an all-laser technique immediately became the standard of care in my practice.

IntraLase (IntraLase Corp., now Abbott Medical Optics Inc., Santa Ana, California) was founded in 1997 to commercialize a laser-based process that would virtually eliminate sight-threatening complications reported with microkeratomes. The rest, just 13 short years later, is already history. In the meantime, three other platforms became available for refractive surgery (Femto LDV [Ziemer Group, Port, Switzerland]; Technolas 520F; VisuMax [Carl Zeiss Meditec, Jena, Germany]), with a fifth one on the way (FS-200; WaveLight AG, Erlangen, Germany). In this cover focus, Günther Grabner, MD, gives an extensive overview of the available lasers. He lists the differences and technical specifications of each device for flap creation and gives you a good understanding of recent advances made with this technology.

To balance Dr. Grabner's article, Wayne Crewe-Brown, MD, addresses the complications associated with femtosecond laser flaps. Many of the same complications can occur with conventional microkeratomes, but surgeons should be aware of the additional complications, such as opaque bubble layer and horizontal and vertical gas breakthrough, that are unique to the femtosecond laser. In his article, Dr. Crewe- Brown points out that the single-most important reason for converting to femtosecond flaps is suction breaks. They are a devastating complication with microkeratomes, but can easily be handled when performed with a femtolaser.

But the femtosecond laser isn't just for flap creation anymore. Mark Tomalla, MD, presents an overview of numerous new applications and reviews considerations for this relatively new technology. For instance, there has emerged a new generation of femtosecond lasers—those able to perform crucial steps in cataract surgery. Three companies, LensAR, Inc. (Winter Park, Florida), LenSx Lasers Inc. (Aliso Viejo, California; recently proposed to be acquired by Alcon Laboratories, Inc., Fort Worth, Texas), and OptiMedica Corp. (Santa Clara, California), are proposing this technology to perform the anterior capsulotomy as well as nuclear fragmentation and incisional architecture. Will this technology help us to achieve better results and less complications? This cover focus provides an overview of the available systems and recaps previously released and published clinical results.

We are only at the dawn of realizing what these femtosecond laser systems are capable of. A new era in what I would like to call truly refractive cataract surgery is fastly emerging with this technology. Recently, a small group of surgeons have been testing femtosecond laser applications in corneal surgery. In this edition, Thomas Neuhann, MD, and Luca Buzzonetti, MD, provide the case for performing keratoplasty and deep anterior lamellar keratoplasty with the intrabubble technique, respectively; these approaches have provided more reproducible results in their hands. According to my friend and Co-Chief Medical Editor, Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth, femtosecond technology has added a whole new dimension to corneal surgery. I could not agree more, as this technology has allowed innovation to take place worldwide.

More developments are on the way, improving the efficacy, safety, speed, and applications of femtosecond lasers. It was always a thrill for me to be a refractive surgeon, but this technology continues to amaze me.

Erik L. Mertens, MD, FEBOphth Chief Medical Editor