We as ophthalmologists should consider ourselves fortunate. We live in a great time for eye surgery, with access to technological advances that would have been regarded as science fiction when I was in training more than 20 years ago. Patient outcomes have been phenomenal with LASIK and flap creation using femtosecond lasers, and now, thanks to new femtosecond laser models, results of cataract surgery have not only caught up with but have even surpassed those of laser refractive surgery.
Laser-assisted cataract surgery has given us the ability to provide most patients with complete spectacle independence. Refractive surgery patients have brought a whole new stream of revenue, and demographics in Europe and the United States are conspiring to ensure that we will be busy in the coming years performing cataract surgery. However, the advent of this latest form of cataract surgery has brought about similar controversies to those seen when femtosecond lasers for refractive surgery were introduced—when naysayers argued that a laser was not essential for LASIK flap creation. It is interesting to see that many of those naysayers have now become major advocates of laser-assisted cataract surgery.
MAKING THE CHOICE
I have over the years developed a good relationship with Bausch + Lomb. As a consultant to the company, I was well informed about the progress of its Victus Femtosecond Laser Platform. Late to start, the project for performing cataract surgery came to fruition within 3 months of conception in 2010.
In August 2011, I had, with the kind courtesy of Kasu Prasad Reddy, MD, the opportunity to use a prototype of the laser in Hyderabad, India. Unlike current femtosecond lasers, this prototype had a microscope through which laser surgery could be viewed in 3-D. That stereoscopic view of a perfect capsulotomy and lens fragmentation made me realize that laser-assisted cataract surgery was the future. It is a pity that no current commercial lasers provide a 3-D view, as surgeons are missing the wow factor of really seeing what the laser is capable of doing.
Convinced that laser-assisted cataract surgery was worth the investment, I did my due diligence and researched other laser systems. I did not have much in the way of relationships with the other companies, and they did not seem too enthusiastic about placements in the United Kingdom; this made my choice fairly easy. The additional capability of performing refractive surgery (LASIK flaps) and therapeutics (corneal transplants and corneal tunnels for intrastromal corneal ring segments), made the Victus even more attractive.
DEALING WITH THE COST
The trickiest area to consider was cost. After looking at various scenarios that made economic sense, we concluded that all patients suitable for laser-assisted cataract surgery should undergo the procedure as a standard of care. When we first acquired the IntraLase (now Abbott Medical Optics Inc.) in 2004, we offered the technology at a premium price; however, no patient opted for microkeratome LASIK. Subsequently, we put our microkeratomes away for good and offered only the IntraLase. Likewise, a similar argument can be made for laser-assisted cataract surgery: If we believe it is better, then why are we offering a substandard option to patients?
There are two economic arguments in favor of making laser-assisted cataract surgery the standard of care: (1) the incremental cost increase can be calculated more accurately based on current volumes, and (2) the additional cost is lower with the capital costs and maintenance distributed over a larger (and predictable) volume of patients. Today, we provide laser-assisted cataract surgery at a more affordable—albeit still expensive—price, and we have not seen any drop in surgical volume. In fact, we have seen a modest increase.
Combined with the increase in revenue, we are covering costs. The per-click fee for all cataract surgery laser manufacturers is still high. With increased competition and difficulty in securing laser placements because of economic issues, the per click price point will, I believe, have to come close to the pricing for LASIK flaps.
Several myths about laser-assisted cataract surgery are gradually being dispelled, including that it slows down surgery. This might have been the case initially, when we were learning how to deal with patient flow. Our laser is positioned in our operating theater, and we perform the whole procedure at one time. It takes between 2 and 3 minutes to perform the laser portion of the procedure, and, with the capsulotomy already performed and the lens prechopped, we save at least 1 minute intraoperatively.
In May 2013, at a live surgery demonstration at our center (sponsored by Bausch + Lomb and TrueVision Systems, Inc.), four cases were performed comfortably in 70 minutes using one operating room. For a video of the demonstration, visit eyetube.net/?v=lirel.
More than 90% of our patients undergo premium lens surgery with multifocal (trifocal) IOLs. Our laser enhancement rate to correct residual astigmatism or spherical error used to be 1% to 2%. Anecdotally, with 800 cases performed since adoption of the laser, I have had only one eye of one patient that needed a PRK to correct a -1.00 D refractive error postoperatively. We are currently auditing our visual outcomes and comparing these to the pre-Victus era.
A NEW TECHNIQUE
New technology brings innovation, which is exciting for those of us who like to test the boundaries. Through a mistake, I fortuitously discovered a way of mobilizing and fragmenting the lens in laser-assisted cataract surgery.
To avoid capsular block and posterior capsular tears, I used to use a cannula to break up the lens and release the retrolental pocket of gas formed during laser fragmentation. One day, by mistake, while breaking up the lens, I injected fluid into a fragmentation incision and noticed a posterior fluid wave and mobilization of the lens. I proceeded to do this in following cases and found that it was reproducible.
Working with Bausch + Lomb Technolas, we developed the Daya Translenticular Hydrodissection Cannula to simplify the process of hydrodissection and lens fragmentation (Figures 1 and 2). Ultrasound times using this method have been statistically significantly lower than with no hydrodissection. 1
Other clinical benefits of laser-assisted cataract surgery include the ability to perform surgery in fairly complex cases, such as a subluxated lens in Marfan syndrome, which requires an eccentric and small capsulotomy (Figure 3). Another memorable case was a patient with Stevens-Johnson syndrome, symblepharon, and a cloudy cornea. Viewing the lens with online optical coherence tomography (OCT) simplified the procedure, and I was able to perform an almost perfect capsulotomy with no struggle. Patients with complex anterior segment anatomies benefit from this new technology, and, as a premium and specialist provider, our center is proud to be able to deliver this level of care.
Laser platforms for cataract surgery will go through an iterative process of improvement, and I am excited to be involved in development of the Victus. The future looks promising, with more available options and improved user interfaces and performance. I have no doubt that laser-assisted cataract surgery will become the gold standard in the developed world. Although some of the current benefits may seem small, added together they will be quite significant in due course.
Over the past 2 decades of practice, I have noticed that technologies (therapeutic or diagnostic) that benefit patients and make life easier for surgeons become widely adopted. I believe this will be true of laser-assisted cataract surgery.
Finally, I think the terminology we use -laser-assisted cataract surgery - must be changed to reflect the large and ever-increasing proportion of refractive lens exchange procedures we perform. Perhaps laser-assisted lens exchange is a better alternative terminology that encompasses both.
Sheraz M. Daya, MD, FACP, FACS, FRCS(Ed), FRCOphth, is Director and Consultant of Centre for Sight, East Grinstead, United Kingdom. Dr. Daya is also a Chief Medical Editor of CRST Europe. He states that he has no financial interest in the products and companies mentioned in this article. He may be reached at e-mail:email@example.com.
- Daya S, Nanavaty M, Espinosa Lagana M. Trans-lenticular hydrodissection, lens fragmentation and influence on ultrasound power in femtosecond laser cataract surgery. J Cataract Refract Surg. [In press.]