Femto-phaco has potential for revolution in ophthalmology
The use of femtosecond lasers in cataract surgery means the introduction in our surgical world of a new revolutionary possibility. The word “laser” always sounds like a magical term for patients and supposes access to a high level of accuracy and precision, higher than any mechanical procedure conducted by the hand of a surgeon.
However, the use of femtosecond lasers in the field of crystalline lens surgery still raises crucial questions. When we consider that phacoemulsification nowadays is perfectly controlled, combining microincision, fluidics regulation and refined micro-instrumentation and guaranteeing a high level of predictability, adjustability and safety, what could be the interest in introducing a laser that would make the platform heavier?
The femtosecond laser is currently used to perform the first step of the surgery, consisting of a perfectly controlled incision and the rhexis, associated with the fragmentation of a nucleus that should preferably be not too hard. But then the cortex and masses need to be aspirated by a phaco handpiece to allow the classical manual implantation of the IOL.
This strategy establishes a complete reorganization of the surgical protocol in terms of location, duration and task delegation for the accomplishment of an operation that will inevitably take a longer time. Probably the only added value will be a higher level of accuracy that will optimize the final outcome of premium IOLs with no induced astigmatism and perfect centration and positioning of the implant. However, only surgeons experienced in the art of phaco commonly use these refractive lenses, when femtosecond lasers should theoretically support operators with low-volume surgical practices.
This raises an important point: We have no financial model to incorporate femtosecond laser technology into cataract surgery, and this is a primary concern at a time of downward reimbursement conditions for cataract surgery in many European countries. The combination of a femtosecond laser with a phaco machine would create a significant extra cost.
Undoubtedly, only centers with high-volume procedures will be able to offer it, assuming that several surgeons will be using a single platform. It is easy to understand why the development of femtosecond laser platforms capable of offering all surgical options, from the lamellar corneal cut (flap, tunnel for intracorneal ring implantation, corneal grafts) to the lens, is gathering the interest of researchers. Multitask platforms would save space and reduce costs.
Opponents to the concept persist in assuming that femtosecond lasers will lead to the end of surgery in ophthalmology by introducing a technical procedure that does not need any specific surgical ability. This is a question that remains.
Does this situation not seem reminiscent of the early beginnings of phaco itself, when it took time to convince extracapsular followers of its value? Or of the advent of femto-LASIK, which was adopted by some surgeons simply to increase the visibility of their centers? We must admit, however, that all those who started using the femtosecond laser to perform the LASIK cut have put their microkeratome aside.
To measure the exact stake of this new technology on our practices, we are invited to consider the interest aroused by the exhibits at international congresses. These exhibits present the newest femto-phaco machines and attract the interest of the entire ophthalmic community. It seems that the majority of us would be ready to get one of these new machines if the financial investment was not so huge.
If we can assume that not only presbyopic lens exchange, but also more cases of cataract extraction, are nowadays to be considered as a new chapter of refractive surgery, the femtosecond laser will probably represent the next step of modernization in this field. And who wants to stop progress and the goal of perfection?
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Béatrice Cochener, MD, PhD, is OSN Europe Edition Chairperson of the Editorial Board. She can be reached at University Hospital of Brest CHRU MORVAN, LaTIM (laboratory of Medical Informations Treatment). Batiment IV, 5 Ave. FOCH, 29609 Brest. Cedex, France; +33-2-98-22-34-40; email: email@example.com.
Disclosure: Dr. Cochener has no relevant financial disclosures.