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Similar a Femtosecond Laser Cataract Surgery – Magic or Myth?
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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
- 8. • Perform capsulotomy safely and completely, resistant to tearing • Central, circular and reproducible – anteroposterior effective lens position – lateral centration – IOL calculations • Predictably overlap IOL edge by 0.5mm Anterior Capsulotomy
- 9. Anterior Capsulotomy • Most striking feature of day 1 appearance • Published evidence?
- 10. Anterior Capsulotomy • Nagy – 100% of anterior capsulotomies within 0.25mm vs 10% of manual
- 11. Anterior Capsulotomy • Tackman, Friedman – less deviation from intended diameter – increased circularity
- 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
- 20. Ability to customise reproducible, multiplanar corneal wounds shown in multiple studies Corneal incisions
- 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
- 23. Latest Results
- 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
- 31. Thank You