Dr Gagan Khannah
Ophthalmic Surgeon
Eastwood Eye Surgery
Macquarie University Hospital
Sydney Eye Hospital
PresMed Annual Optometrist Conference
10th March 2013
http://eesc.com.au
Call Girls Shahdol Just Call 8250077686 Top Class Call Girl Service Available
Femtosecond Laser Cataract Surgery – Magic or Myth?
1. Eastwood
Eye Surgery
Dr Gagan Khannah
Ophthalmic Surgeon
Eastwood Eye Surgery
Macquarie University Hospital
Sydney Eye Hospital
PresMed Annual Optometrist Conference
10th March 2013
Femtosecond Laser Cataract
Surgery – Magic or Myth?
A Balanced View!
3. • Individual steps of laser assisted
cataract surgery (LACS)
– Anterior capsulotomy
– Nuclear fragmentation
– Corneal incisions
• Hypothetical benefits
• Discuss the current evidence base
– very early days in adoption of LACS
– further discussion of clinical impression
Agenda
4. Does LACS:
• Improve precision and reproducibility?
• Improve safety?
• Improve refractive outcomes?
Questions
5. • Are the benefits statistically significant:
– Result unlikely to occur by chance
– Does not mean result is important or
meaningful
• Are the benefits clinically or practically
significant
• Is the benefit worth the extra time, cost
and effort
Assessing evidence for new
technology
6. • High resolution anterior segment
imaging coupled to femtosecond laser
• Anterior capsulotomy
• Nuclear fragmentation
• Corneal incisions (primary, secondary
and arcuate incisions)
Capabilities of LenSx laser
12. Anterior Capsulotomy
• Zoltan Nagy
– Series of studies
– Less IOL tilt and decentration
– Better IOL-anterior capsule overlap
– Decreased higher order aberrations
• Clinical significance?
– No definite improved refractive result (sphere,
cylinder or unaided visual acuity)
– Longer term studies required
– Subgroup analysis required
14. • Effectively disassemble the nucleus
• Safety: protection of posterior capsule
• Safety: reduction in total phaco power
and protection of corneal endothelium
Femtosecond nuclear
fragmentation
15. • No reports of femtosecond laser direct
damage to posterior capsule
• Offset from posterior capsule on imaging
appears to be effective in preventing this
Nuclear fragmentation
- safety
16. • Reducing need to go deeper with phaco tip
may reduce risk of PC rupture
• 0.31% PC rupture rate lower than reported
incidence of 0.53% - 2.7% in manual surgery
Nuclear fragmentation
- safety
17. • Decreased total phaco energy confirmed to
statistically significant level in multiple studies
• Close to 50% reduction in both total phaco
energy and phaco time
• May reduce damage to
corneal endothelium
• May reduce potential for
inflammation and
corneal burns
Nuclear fragmentation
- safety
18. • Statistically significant reduction in phaco
energy in all grades of cataract
• No studies yet to confirm reduction in
endothelial cell loss. Further long term studies
required.
• May be particularly important in patients with
Fuch’s dystrophy
• Younger patients
Endothelial protection
21. • Reproducible
wounds may allow
more consistent
surgically induced
astigmatism
• No large studies
published
at this stage
Corneal incisions
22. • Endophthalmitis a rare but devastating
complication
• Well constructed clear corneal wounds may
reduce the risk of endophthalmitis
• Difficult to study: incidence 0.13%
• A lot of data would be required to prove a
benefit in reducing endophthalmitis
Corneal incisions
24. • In this section, focus on objective current
data, not on our clinical impression
• Objective data already demonstrates
that LACS is no worse than manual
phaco
– Short learning curve
– Would not have been able to say this about move
from ECCE to phaco in first 12 months
– Took until 2001 for first large scale RCT proving
cost effectiveness of phaco vs ECCE
Conclusions
25. • New technology
– experience rising very rapidly
– 30,000 cases, almost all in the last 12 months
• Data demonstrating statistically significant
benefit in a number of areas
– at this stage relatively little definite clinically
significant data
– large number of studies currently underway
– longer term studies, eg endothelial cell loss
Conclusions
26. • Positive initial impressions, not
discouraged by:
– inability to immediately have clinically significant
evidence base
– new complications
– increases in cost
• As technology and techniques mature, history
suggests:
– complications decrease
– equipment costs reduce with widespread adoption
– outcomes and efficiencies improve
– Other technologies develop
Conclusions
27. Eastwood
Eye Surgery
Laser Refractive Cataract
Surgery
Provides Image –
guided, surgeon
control to perform:
– Anterior capsulotomy
– Lens fragmentation
– Corneal incisions
4 systems currently in
development
28. Eastwood
Eye Surgery
Laser Refractive Cataract
Surgery
Possible Advantages
– Automates steps of cataract surgery
– Improved corneal incisions & astigmatism
control
– Improved capsulotomy for effective lens
positioning
– Less phaco energy and endothelial cell loss
29. Eastwood
Eye Surgery
Laser Refractive Cataract
Surgery
Disadvantages
– Topical anaesthesia
– Cost
– Limitations
Small pupil
Corneal opacity
Dense cataract
Keratoconus
30. Eastwood
Eye Surgery
Laser Refractive Cataract
Surgery
Exciting technology and future is bright
Still in its infancy and benefits unclear
Requires better safety data & research
Costs must be addressed
Secondary advances may revolutionise
cataract surgery
