Roberto Bellucci, MD

Laser-assisted cataract surgery (LACS) is still under development. Although many ophthalmology society meetings now dedicate entire sessions and symposiums to this topic, most surgeons are waiting for clinical evidence of improvement over a phaco-only approach before they make the switch to LACS. At this time, only surgeons who advocate in favor of the new technology have reported this type of improvement; therefore, skeptics of the femtosecond laser have expressed doubts about the future of its use in cataract surgery. In my opinion, the femtosecond laser will be increasingly used in cataract surgery for 10 reasons.

Reason No. 1: Improvements in machinery. After first experiences, it is clear that many problems encountered with femtosecond lasers in cataract surgery stem from a few features of the machines that are currently under revision or already have been revised. For starters, docking methods have been updated with each new laser model, and the limitations of hard docking (ie, possible retinal problems) and soft docking (ie, eye micro-movement) are now fully understood. Certain characteristics of the patient interface have also been revised, thus minimizing suction loss. In my 3-year experience, I have had not one suction loss.

Reason No. 2: Better energy tuning. Whereas phaco energy can be adjusted during routine cataract surgery, femtosecond energy must be tuned in advance of LACS procedures. An optimal setting will produce few bubbles and direct most of the energy to tissue cutting; each laser can now be regulated in this way. Additionally, femtosecond energy is sensitive to opacity, but phaco energy is sensitive to hardness only, and this concept is also improving machine tuning.

Reason No. 3: Better and more efficacious fragmentation patterns. With the help of LACS, we are close to abandoning phacoemulsification in grades 2 and 3 cataracts, with advantages in terms of energy reduction and tissue trauma. This is especially helpful in the presence of a diseased endothelium.

Reason No. 4: An increasing desire for a perfect capsulotomy. A perfectly round and centered capsulotomy can be achieved only with a femtosecond laser, and this is a prerequisite for perfect centration of high-technology IOLs in the capsular bag. By removing capsulotomy variability, the femtosecond laser can help surgeons to provide the best available care to patients, and also to understand the reasons behind imperfect results. Additionally, a perfect and reproducible capsulotomy will make the evaluation of new IOLs quicker.

Reason No. 5: Better handling of difficult cases. LACS is especially beneficial in eyes with shallow anterior chambers, intraoperative floppy iris syndrome, lens subluxation, nystagmus, and other difficult characteristics because surgery is safer and more reproducible.

Reason No. 6: Increasing evidence of better results. Clinicians converting to femtosecond surgery always say their results have improved, with quicker eye recovery. Although this is a common impression, recent reports have found no relevant differences between outcomes with LACS and routine phaco procedures. We need to institute precise parameters when investigating this subject because, if the question is, “Are LACS and routine phaco effective cataract surgery techniques?” the obvious answer at present is, “Yes, with no differences.” Additionally, large studies will be needed to detect whether the complication rate is similar between the two techniques.

Reason No. 7: Positive patient perspectives. Patients like new techniques, especially when they tend to substitute for the surgeon in performing delicate maneuvers. Regardless of the confidence they have in us, patients prefer being treated by a machine. It is not wise to let patients drive their care, but their acceptance will push the technique forward, helping to provide relevant resources and funding.

Reason No. 8: Improving surgeon perspectives. Surgeons also like new techniques and their development. The femtosecond laser is attractive to surgeons in that it reminds them of robotic surgery. Reproducible surgery is an attractive goal for surgeons; with femtosecond lasers, we can do virtually the same procedure in every eye. Therefore, the preoperative discussion with patients can concentrate on IOL options rather than on possible surgical complications.

Reason No. 9: Clearing up misunderstandings in health care systems. At the moment, the potential of LACS is not fully understood by public health systems. The cost of doctors’ educations and wages and the shortage of physicians might induce national governments to treat LACS as a nonsurgical technique that can be performed in part by nonphysicians. There is a risk here for our profession that cannot be neglected, although we will never be replaced as the single most responsible party for patients’ surgeries and health.

Reason No. 10: A forward-thinking industry perspective. The huge investments companies have made in the past several years have already produced improvements in the available LACS technologies. In the past 3 years, specifically, femtosecond lasers have undergone the same evolution that phacoemulsification made during its first 15 years. It is easy to foresee further evolution in the technology, with reduction of costs paralleling its diffusion.

These 10 factors will probably double the number of LACS units installed in Europe by the end of 2015. Speaking with company representatives, I have heard that they are having difficulties producing enough lasers to match the demand. As an early user, I welcome the development of LACS and the start of a new surgical era for cataract surgery.

Roberto Bellucci, MD, is Chief of the Ophthalmic Unit, Hospital and University of Verona, Italy. Dr. Bellucci states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: robbell@tin.it.

H. Burkhard Dick, MD, PhD

It is no exaggeration to call the femtosecond laser’s entry into cataract surgery an almost unmitigated triumph, as most of the doubts expressed, even by high-volume users, are economic and not surgical. What looked at first glance like a nice addition to premium care (and premium IOLs) has in a short time proven its worth in a wide spectrum of complicated cases and in patients with special demands. We have been able to adjust the system so that old and young patients alike profit from LACS; for instance, intumescent lenses can be operated on without a single dreaded Argentinian flag syndrome in a large series,^1-5 and pediatric cataracts can be successfully removed after some adjustments of the equipment. A zero-phaco approach particularly benefits patients with compromised corneas.

Given the widespread—though not universal—acceptance of the femtosecond laser, we can reasonably expect further, consistent rises in the numbers of centers using this technology and of patients undergoing LACS in 2015. Given the fact (or is it just a feeling?) that steep prices have been the most difficult hurdle for LACS, we should experience a quantum leap the moment systems become cheaper and more versatile. There are indications that this crucial moment may not be far off. Easier availability of femtosecond lasers will be met by greater patient demand, and let us never underestimate the attraction that the word laser has for the general public. With more information on the benefits of LACS available, people will specifically ask their eye surgeons for this surgical option. Additionally, patients’ posts about bladeless surgery on social media speak for themselves; call it market pressure.

There is no shortage of surgical techniques that have been paired with LACS, both those that are proven and those that are encouraging but still require larger case numbers and clinical evaluation. These techniques include mini-capsulotomy, the rescue technique, and primary posterior laser-assisted capsulotomy (Figure 1), to name a few.^6-8 The latter has the potential to create a barrier to lens epithelial cell migration. There is a distinct possibility that, performed during LACS, this step might work as a prophylaxis to posterior capsular opacification (PCO) at no additional cost to the surgeon or patient. It would be a welcome irony if cataract surgery, the most frequent intervention in ophthalmology, could render PCO laser treatment, the second most frequent intervention in our discipline, obsolete.

In 2015, a wider variety of femtosecond-specific IOLs (Figure 2) will become available. These IOLs and the patients who receive them will benefit enormously from an ophthalmic viscosurgical device-free technique, which is possible with complete laser lens fragmentation. What is still needed, however, is for preoperative diagnostics to become fully integrated into—and ideally performed with—the laser unit, including accurate (literally to the micron) three-dimensional (3-D) measurement of the patient’s anatomy. Once diagnostics are integrated into these units, choosing the appropriate IOL will also be done with the system.

Most current systems are rather bulky; however, much smaller and more mobile laser systems will soon become available and will incorporate indispensible key technologies such as intraoperative topography, aberrometry, and, even more brilliant and impressive than spectral-domain optical coherence tomography, 3-D imaging systems.

By the time femtosecond laser systems for cataract surgery become smaller, we will be performing laser cataract surgery—the assisted in our current term long gone—and, without major adjustments, a variety of refractive and therapeutic procedures as well. In addition to performing cataract surgery, the laser of the future will cut a flap for the myopic patient, prepare a pocket for intrastromal corneal inlays, create incisions, and perform keratoplasty in patients with severe corneal scars. These jack-of-all-trade units will be symbols of a new era in ophthalmic surgery, one in which the borders between refractive, cataract, and rehabilitative surgeries are a distant memory, just like the phaco tip.

H. Burkhard Dick, MD, PhD, is a Clinical Professor at and Chair of the University Eye Hopsital of the Ruhr University in Bochum, Germany, and the Director of the Institute of Visual Sciences at Ruhr University. Professor Dick is a member of the CRST Europe Editorial Board and states that he is a consultant to Abbott Medical Optics. He may be reached at e-mail: Burkhard.Dick@kk-bochum.de .

1. Dick HB, Schultz T. Laser-assisted cataract surgery in small pupils using mechanical dilation devices. J Refract Surg. 2013;29:858-862.
2. Conrad-Hengerer I, Hengerer FH, Joachim SC, et al. Femtosecond laser-assisted cataract surgery in intumescent white cataracts. J Cataract Refract Surg. 2014;40:44-50.
3. Dick HB, Schultz T. Femtosecond laser-assisted cataract surgery in infants. J Cataract Refract Surg. 2013;39:665-668.
4. Schultz T, Ezeanosike E, Dick HB. Femtosecond laser-assisted cataract surgery in pediatric Marfan syndrome. J Refract Surg. 2013;29:650-652.
5. Conrad-Hengerer I, Hengerer FH, Schultz T, Dick HB. Femtosecond laser-assisted cataract surgery in eyes with a small pupil. J Cataract Refract Surg. 2013;39:1314-1320.
6. Dick HB, Schultz T. Femtosecond laser-assisted capsulotomy rescue for capsulorhexis enlargement. J Cataract Refract Surg. 2014;40:1588-1590.
7. Dick HB, Schultz T. Primary posterior laser-assisted capsulotomy. J Refract Surg. 2014;30:128-133.
8. Dick HB, Canto AP, Culbertson WW, Schultz T. Femtosecond laser-assisted technique for performing bag-in-the-lens intraocular lens implantation. J Cataract Refract Surg. 2013;39:1286-1290.

Günther Grabner, MD

The number of centers offering LACS should grow steadily in 2015, but the technology will most likely continue to be used in combination with premium services, such as multifocal, trifocal, and toric IOLs and astigmatism-correcting incisions. This is mainly because we are still waiting for the prices of femtosecond laser systems to go down. Once patient interfaces are cheaper, surgeons will begin to make this technology available to more patients, including those presenting for routine cataract surgery. I have no doubt that competition among the laser companies will help bring prices down to a widely accepted level and that this technique will be offered in public hospitals in the near future.

I also expect that several new laser-specific lenses will come to the market in 2015; a few are already available. These laser lenses are designed to closely fit into the capsulorrhexis, thereby eliminating the risk of rotation, rendering perfect centration and orientation of toric IOLs more easily achievable, and decreasing the risk for secondary cataract. This, of course, must be confirmed by long-term studies.

The third point is that surgeons will be able to perform intrastromal corneal incisions—intrastromal arcuate keratotomy (ISAK)—to treat low amounts of astigmatism (0.50 to 3.00 D) in nearly all patients who require optimization of distance visual acuity. Once precise nomograms are created for this procedure, the number of patients treated with ISAK and LACS may increase by 20% to 25%.

Lastly, I believe that simultaneous sequential bilateral LACS is the procedure of the future (Figure 3). As confirmed in the landmark endophthalmitis prophylaxis study,¹ the rate of endophthalmitis is lower than we previously thought possible; therefore, the chance of endophthalmitis occurring bilaterally is basically nil. Additionally, the level of precision of biometry for calculating IOL power is so good that few patients would be better off waiting 3 or 4 weeks in between procedures. Two further arguments for simultaneous sequential bilateral LACS are that patients like it, especially because only one postoperative care regimen is needed, and that it saves the economy a lot of money.

Günther Grabner, MD, is Professor of Ophthalmology and Chairman of the University Eye Clinic at Paracelsus Medical University in Salzburg, Austria. Professor Grabner may be reached at tel: +43 662 4482 3700; e-mail: g.grabner@salk.at

1. Barry P, Seal DV, Gettinby G, for the ESCRS Endophthalmitis Study Group. ESCRS study of prophylaxis of postoperative endophthalmitis after cataract surgery: Preliminary report of principal results from a European multicenter study. J Cataract Refract Surg. 2006;32(3):407-410.