One of us (H. Burkard Dick, MD, PhD) was the first surgeon in the world to use the commercial Catalys Precision Laser System (OptiMedica Corp.) in November 2011. Before making the decision to adopt laser-assisted cataract surgery, however, it was important to consider how this technology would affect the practice and, ultimately, the services offered to patients. One of the most important aspects was investing in a laser system that would be adaptable to future applications.

INITIAL INVESTIGATION OF EARLY LASER CATARACT SYSTEMS

When I began investigating the technology, peers who had adopted early-generation laser cataract systems were not completely satisfied. Their outcomes were sometimes less than desired, particularly given the cost of the technology. I thought about my patient base: they are typically older individuals (mean age, 74 years) who, in many cases, cannot fixate or follow the directions of the surgeon. Also, they may not hear well, they are likely to have other comorbidities that could negatively influence postoperative outcomes, and they do not always want to undergo surgery with topical anesthesia. Therefore, at the time, I did not make the investment in laser-assisted cataract surgery.

Another finding in my initial investigation of laserassisted cataract surgery systems suggested that, unlike other technologies in ophthalmology, the platforms are quite distinctive. Marketing language may make them sound the same, but there are important differences in the components and integration of each system. I wanted several functions in particular for my practice, such as being able to set up the laser in the operating room, and I eventually found them with the Catalys (Figures 1 through 5). Although this may not be true in other countries, in Germany, procedures must be done under sterile conditions if the eye is opened. At the time, this capability was available only with the Catalys.

BENEFITS OF LASER-ASSISTED SURGERY

A video library of some of my laser-assisted cataract surgery cases is available on the IrcsBochum YouTube channel. In the past 2 years that I have been using this technique, I have realized several benefits of laser-assisted surgery with Catalys.

No. 1: I have been able to eliminate the use of ultrasound energy in nearly all cases. This includes patients with comorbidities such as glaucoma, pseudoexfoliation syndrome, loose zonules, hard lenses, corneal endothelial problems, and Fuchs dystrophy. In my most recent 100 cases, I used ultrasound energy in only three eyes; the others required only irrigation and aspiration.

No. 2: Postoperatively, patients achieve better visual acuity. We have evaluated the use of laserassisted cataract surgery in several ways, including a study of visual rehabilitation and outcomes based on BCVA. In this prospective, randomized, intraindividual comparison, bilateral cataract surgery was performed under topical anesthesia with the Catalys in one eye and a standard cataract surgery technique in the other. Postoperative examinations were scheduled for days 1, 3, 5, and 7 and 1 month. In this adequately powered study, we found statistically significantly better BCVA starting on day 1 in laser pretreated eyes. On day 7, laser pretreated eyes had achieved 1 more line of BCVA than eyes treated with standard cataract surgery. The difference was no longer statistically significant at 1 month, but at a minimum the better visual acuity on day 7 confirmed that patients recover faster after laser-assisted cataract treatment (data on file with OptiMedica).

No. 3: Laser-assisted cataract surgery induces no more inflammation in eyes with small pupils than a standard technique. Although the inflammatory response to cataract surgery is minimal, thermal changes and issues with prostaglandins can occur in eyes with small pupils. To assess the risk for increased inflammation with laser-assisted cataract surgery, we conducted a prospective, randomized study using laser flare photometry (FM-500 Flare Meter; Kowa Co. Ltd.) and found that, on postoperative day 1, eyes treated with the Catalys had 20% less inflammation than those that had undergone standard cataract surgery. No other differences were observed (data on file with OptiMedica).

No. 4: Laser-assisted cataract surgery induces a lower rate of endothelial cell loss than a standard technique. In our prospective, randomized study, compared with microincision cataract surgery using the Stellaris PC (Bausch + Lomb), eyes that underwent laser-assisted cataract surgery had statistically significantly less (41%) endothelial cell loss at 3 months. This difference may be attributed to lower ultrasound energy used in the laser cohort, as effective phaco time was reduced by approximately 90% ¹

As part of this study, we also compared fluid use and overall procedure time with laser-assisted and standard cataract surgery techniques to determine whether aspiration without the use of ultrasound caused greater fluid turnover and, therefore, potentially induced greater endothelial cell loss. We found no difference in fluid turnover, with a mean of approximately 90 mL of balanced saline solution administered in all eyes. Additionally, the length of the procedure was essentially the same in both groups.

No. 5: I have enjoyed financial success and am using laser cataract surgery technology in more cases than I anticipated. I had projected performing 2,000 cases using this technology in the first 2 years after its adoption. Since November 2011, however, I have already completed about 2,250 cases. Although I work in a financially depressed area, the population is large, and I treat an estimated 4,000 cataracts per year. My patients pay €1,580 on top of standard cataract surgery costs for laser-assisted cataract surgery.

PATIENT EDUCATION

TION My approach to introducing laser-assisted cataract surgery to patients has been relatively low key. Recruitment and patient education are the preferred strategies; I do not advertise. We stress the differences between laser-assisted cataract surgery and standard surgical approaches, explaining the advantages of the former. This is especially important with patients who have complex situations. If they see value in having surgery with the aid of the laser system, they are more willing to agree to it and pay the added cost. I have found that explaining the potential advantages in each case and discussing the pros and cons on an individualized basis is the best strategy for patient education.

In talking to surgical candidates, I offer as much information as I can, but I avoid exaggeration. For example, patients often ask if laser-assisted cataract surgery is a safer procedure, and the answer we give is that we do not know for certain but that our current evidence suggests it is. We inform patients that every case is videotaped and documented to evaluate safety and effectiveness. We also share facts about the complication rate, which is 0.32% in the more than 1,270 cases we have analyzed to date (personal data). The message we want to convey to candidates is that the procedure is more accurate, more customized, and more precise, but it has not yet been definitively found to be safer.

POSSIBLE RISKS

No. 1: It is important to plan a responsible rollout. As my colleagues and I prepared to perform laser-assisted cataract surgery, we were cautious and conservative because the technology was so new. But because some of our peers have reported good results with the technology, ^2,3 we were encouraged that we were heading in the right direction. Among the many things we accomplished prior to performing our first cases, we revised our patient consent forms and arranged for additional payment options.

No. 2: There are always critics of new technology. While we were optimistic regarding the merits of laserassisted cataract surgery, not everyone in our referring network was—at least initially. One of our colleagues told me that if I operated on one of his patients with a femtosecond laser he would not refer any others. But then he sent me a relatively young patient with bilateral cornea guttata who had undergone keratoplasty after cataract surgery in one eye and also had a significant hard cataract in her other eye. Immediately after I performed laser-assisted cataract surgery without phacoemulsification in the second eye, she had a crystal clear cornea, and she did not need a keratoplasty in this eye. Seeing her results, the referring physician began sending me patients already primed for laser-assisted cataract surgery. Now, other doctors are also starting to be convinced that this is preferable to standard cataract procedures.

THE FUTURE

The future of laser-assisted cataract surgery is promising, and I believe that ultrasound will soon be a technology of the past. However, there is much we still need to understand about laser-assisted cataract surgery before it can truly take center stage, and we need to become comfortable with the changes necessary to achieve good outcomes. For instance, redesigned phaco tips and adoption of different laser grid distances and softening patterns for lenses are seemingly minor adaptations that may contribute to significantly reduced ultrasound use. The evidence from clinical trials and the support of referring physicians has shown us that patients can benefit from these changes.

H. Burkhard Dick, MD, PhD, is the Chairman of Ruhr University Eye Hospital, Bochum, Germany. Professor Dick is a member of the CRST Europe Editorial Board. He states that he is a member of the medical advisory board for OptiMedica. Professor Dick may be reached at tel: +49 234 299 3101; e-mail: burkhard.dick@kk-bochum.de.

Tim Schultz, MD, is a resident at the Ruhr University Eye Hospital, Bochum, Germany. Dr. Schultz states that he has no financial interest in the products or companies mentioned. He may be reached at tel: +49 234 299 0; e-mail: tim.schultz@kk-bochum.de.

1. Conrad-Hengerer I, Al Juburi M, Schultz T, Hengerer FH, Dick HB. Corneal endothelial cell loss and corneal thickness in conventional compared with femtosecond laser-assisted cataract surgery: Three-month follow-up. J Cataract Refract Surg. doi:pii: S0886-3350(13)00697-4. 10.1016/j.jcrs.2013.05.033.
2. Friedman NJ, Palanker DV, Schuele G, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg. 2011;37(7):1189-98. Erratum in: J Cataract Refract Surg. 2011;37(9):1742.
3. Palanker DV, Blumenkranz MS, Andersen D, et al. Femtosecond laser-assisted cataract surgery with integrated optical coherence tomography. Sci Transl Med. 2010;2(58):58ra85.