Could femtosecond laser technology encourage more cataract surgeons to perform primary posterior capsulotomy and optic capture?
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Femtosecond laser is a game changer
Yes, as far as primary posterior laser capsulotomy (PPLC) is concerned. By doing femtosecond laser-assisted cataract surgery with standard in-the-bag implantation, 3-D spectral-domain OCT has shown us how wide Berger’s space is after cataract surgery. First, because there is fluid movement through the zonules behind the posterior capsule, balanced salt solution and fluid are turning all round. Second, because the patient is in the supine position, gravitation and partially liquefied vitreous widen the space. Third, because the crystalline lens is removed and even with an IOL in place, there is still sufficient additional space. OCT is consistently able to visualize the posterior capsule, and you set the laser and perform the capsulotomy in a fully automated way. No special surgical capabilities are needed, and there is no danger of damaging the IOL or the vitreous. PPLC never had a great chance in cataract surgery because surgeons understandably were afraid of touching the posterior capsule, but the femtosecond laser is a big game changer. PPLC can now become routine, with the remarkable advantage of preventing PCO forever. Health care can save billions by eliminating the need for YAG capsulotomy, and the patient can avoid visual distortion, flare and halos, maintain the vitreous intact and prevent future problems with, for example, retinal detachment, macular edema and glaucoma.
A posterior optic capture is not necessary within this context. With the femtosecond laser you keep away the manual error, but you need an additional docking, which is only doable with the systems that have a liquid interface and the interface touches peripherally to the limbus. You can choose the size you want and align it with the anterior capsulotomy, which is the ideal situation for pediatric BIL technology. There are controversies because Nd:YAG is a good source of income, and referring doctors and conservative doctors may not like PPLC. A recent prospective randomized intraindividual comparative clinical trial, accepted for publication in the Journal of Cataract and Refractive Surgery, demonstrated the safety and efficacy of PPLC, which can safely be performed by all surgeons with consistent results. The femtosecond laser represents the first achievable solution for the most common complication of cataract surgery. But before this, the laser system will have to be placed in the OR, the laser companies will have to develop the software and approve it as an indication, and reimbursement needs to be increased for the surgeon. Our patients deserve it that we pursue these goals and finally eliminate the complication of PCO.
H. Burkhard Dick, MD, PhD, is chairman of the University Eye Hospital Bochum, Bochum, Germany. Disclosure: Dick reports no relevant financial disclosures.
More studies are needed
While femtosecond laser technology allows a posterior capsulotomy to be made in a predictable way, precision alone will not convince many surgeons to routinely open the posterior capsule in a cooperative adult unless a plaque is present that cannot be polished clean. In the majority of operated adults, YAG laser is never required. Unlike in young children, in whom I open the posterior capsule primarily in every case, routine adult femtosecond capsulotomy and IOL optic capture should await randomized clinical trial evidence that it is better than what we do now.
I applaud innovators because without them we would make no progress. The femtosecond laser has become a mainstay in the armamentarium of the cataract surgeon. However, when it comes to the routine performance of posterior capsulotomy combined with optic capture in adults, I prefer a staged evaluation. I would insist on an initial prospective trial of a small number of patients with close and long follow-up, reported in the peer-reviewed literature. Then a larger number could be evaluated in a multicenter randomized fashion. These steps are needed before endorsing the suggested procedure for routine use in every adult.
M. Edward Wilson, MD, is an OSN Pediatrics/Strabismus Board Member. Disclosure: Wilson reports he has received research grants from Retrophin and Ophtec.