LLF facilitates nuclear disassembly regardless of preferred technique. For divide-and-conquer surgeons, the fragmented nucleus requires less ultrasonic power during sculpting and segment removal, as the smaller fragments are already broken down extensively and can easily be aspirated by the instrument tip. For chop surgeons, the cleavage planes created during LLF facilitate clean fracturing and division of the nucleus into several pieces. For prechop surgeons, LLF creates cleavage planes that allow more complete and controlled division of even very dense nuclei into several segments. To date, no significant safety concerns or adverse outcomes have been reported by these various seminal studies [28▪▪,33▪▪,34▪▪,35▪–40▪]. Edwards et al. [40▪] have demonstrated in a study of 60 laser-treated eyes, the lack of differences in postoperative intraocular pressure and endothelial cell count among laser treated and control eyes.
Adopting new technologies into a clinical practice involves careful assessment of the benefits and costs (Table 2). Individual practices or doctors need to evaluate several parameters (patient acceptance of the technology, willingness to pay, surgical volume, surgical pricing structure, cost of space and personnel) and develop a workable business plan that will show a return on investment. A recent survey conducted about femtosecond cataract surgery (n = 1047 ophthalmologists) revealed that financial issues were their most important concern (72%) followed by reduced workflow efficiency (13%) and patient dissatisfaction or increased expectations (6%) [41▪].
Important considerations for adopting this technology include cost of the femtosecond machine, space, personnel and marketing. Currently, only the LensX machine is commercially available in the USA. In the future, the entry of competing platforms will provide more equipment options and lower femtosecond acquisition costs. A practice also has to consider the cost of additional space to house the femtosecond laser suite. One option is to provide a room large enough to contain both the femtosecond laser and the phacoemulsification machine so that both procedures can be performed in one room. Although this option minimizes patient and surgeon movement, it also prevents continuous use of the femtosecond unit. Another option is to have a dedicated femtosecond room and operator who continuously performs the femtosecond portions of the procedure (LAC, LLF, corneal incisions). The patients are then transferred to the phacoemulsification room for cataract removal. This latter system creates a need for coordination between the two rooms. Ideally, the distance from the femtosecond to phacoemulsification rooms should be short to minimize transport delays. Additional personnel will be needed to incorporate femtosecond cataract surgery. These include the femtosecond operator, which may be a technician or surgeon. Practices with an existing femtosecond flap maker may utilize the same operator for femtosecond cataract surgery. Clinic staff should also be trained to counsel patients on the merits and risks of femtosecond cataract surgery and premium IOLs. A marketing plan is essential to generate patient interest in this new procedure and will entail additional costs (brochures, advertisements, website).
The last but all-important issue is how to recover the cost of adopting the technology. Medicare and commercial payers already cover the cost of the cataract procedure. Neither surgeons nor facilities can charge Medicare or commercial payers additional amounts for using the femtosecond laser to perform cataract surgery. However, surgeons are allowed to charge patients directly, as a noncovered procedure, for femtosecond corneal and limbal relaxing incisons for the treatment of pre-existing astigmatism, which is present in significant degrees (>0.75 D) in about a third of the population. An appropriate informed consent should be obtained in which patients document their understanding of the procedure, the treatment alternatives, and request for the femtosecond cataract surgery as a refractive procedure [42▪].
Femtosecond cataract surgery is a groundbreaking procedure that automates surgical steps and elevates surgical precision to a degree never before achieved. As the technology improves and new outcome and safety data emerge, confidence in the procedure will develop leading to acceptance and adoption by more cataract surgeons which in turn, will lead to the development of new useful applications.
Papers of particular interest, published within the annual period of review, have been highlighted as:
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 75).
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16. Nemet AY, Assia EI, Meyerstein D, et al. Protective effect of free-radical scavengers on corneal endothelial damage in phacoemulsification. J Cataract Refract Surg 2007; 33:310–315.
17. Takahashi H. Free radical development in phacoemulsification cataract surgery. J Nippon Med Sch 2005; 72:4–12.
18. Dodick JM, Christiansen J. Experimental studies on the development and propagation of shock waves created by the interaction of short Nd:YAG laser pulses with a titanium target. Possible implications for Nd:YAG laser phacolysis of the cataractous human lens. J Cataract Refract Surg 1991; 17:794–797.
19. Dodick JM, Lally JM, Sperber LT. Lasers in cataract surgery. Curr Opin Ophthalmol 1993; 4:107–109.
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21. Kanellopoulos AJ. Laser cataract surgery: a prospective clinical evaluation of 1000 consecutive laser cataract procedures using the Dodick photolysis Nd:YAG system. Ophthalmology 2001; 108:649–654.
22. Lin ZD, Feng B, Cheng B, Zou YP. The preliminary study of photolysis for cataract surgery. Zhonghua Yan Ke Za Zhi 2003; 39:601–604.
23. Hoh H, Fischer E. Pilot study on erbium laser phacoemulsification. Ophthalmology 2000; 107:1053–1061.
24. Mian SI, Shtein RM. Femtosecond laser-assisted corneal surgery. Curr Opin Ophthalmol 2007; 18:295–299.
25. Toropygin SG, Krause M, Riemann I, et al. In vitro femtosecond laser-assisted nanosurgery of porcine posterior capsule. J Cataract Refract Surg 2008; 34:2128–2132.
26. Touboul D, Salin F, Mortemousque B, et al. Tissular and mechanical effects observed with an experimental femtosecond laser microkeratome for corneal refractive surgery. J Fr Ophtalmol 2005; 28:274–284.
Frey RW, Edwards K, Naranjo Tackman R, Villar Kuri J, Quezada N, Bunch T, Bott S. Changes in CDE With laser lens fragmentation compared with standard phacoemulsification cataract surgery. Invest Ophthalmol Vis Sci 2010; 51: A434 E-Abstract 5418.
This study demonstrates that LLF can significantly decrease the amount of phacoemulsification energy needed for removal of the crystalline lens. This suggests that LLF can reduce surgical complications attributable to excessive ultrasonic energy such as corneal decompensation.
Nagy Z, Takacs A, Filkorn T, Sarayba M. Initial clinical evaluation of an intraocular femtosecond laser in cataract surgery. J Cataract Refract Surg 2009; 25:1053–1060.
This study is one of the first to demonstrate the feasibility and safety of femtosecond cataract surgery.
29. Assia E, Apple DJ, Tsai JC, Morgan RC. Mechanism of radial tear formation and extension after anterior capsulotomy. Ophthalmology 1991; 98:432–437.
30. Hollick EJ, Spalton DJ, Meacock WR. The effect of capsulorrhexis size on posterior capsular opacification: one-year results of a randomized prospective trial. Am J Ophthalmol 1999; 128:271–279.
31. Peng Q, Apple DJ, Visessook N, Werner L, et al. Surgical prevention of posterior capsular opacification. Part 2: Enhancement of cortical cleanup by focusing on hydrodissection. J Cataract Refract Surg 2000; 26:188–197.
32. Aasuri MK, Kompella VB, Majji AB. Risk factors for and management of dropped nucleus during phacoemulsification. J Cataract Refract Surg 2001; 27:1428–1432.
Tackman RN, Kuri JV, Nichamin LD, Edwards K. Anterior capsulotomy with an ultrashort-pulse laser. J Cataract Refrac Surg 2011; 37:819–824.
This study demonstrates that laser capsulotomy results in more consistently sized and shaped capsule buttons that are subjectively easier to remove. This suggests that laser capsulotomy may facilitate capsulorrhexis in complicated eyes.
Friedman NJ, Palanker DV, Schuele G, Andersen D, et al. Femtosecond laser capsulotomy. J Cataract Refract Surg 2011; 37:1189–1198.
This study demonstrates that laser anterior capsulotomies are superior to manual capsulorrhexis in terms of precision, consistency and strength.
Kranitz K, Takacs A, Mihaltz K, et al. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg 2011; 27:558–563.
This study demonstrates that laser capsulotomy results in reduction of horizontal IOL decentration which may lead to stable and improved refractive outcomes when using advanced technology IOLs.
Nagy ZZ, Kranitz K, Takacs AL, et al. Comparison of intraocular lens decentration parameters after femtosecond and manual capsulotomies. J Refract Surg 2011; 27:565–569.
This study demonstrated that femtosecond lasers create more regularly shaped, sized and centered capsulotomy buttons resulting in better IOL overlap. These results suggest that better refractive stability can be achieve using laser capsulotomies.
Uy HS, Hill W, Edwards KH. Refractive results after laser anterior capsulotomy. Association for Research in Vision and Ophthalmology Annual Meeting. A4695 Poster #D634. Fort Lauderdale, FL; 2011. http://www.arvo.org
These results demonstrate that laser anterior capsulotomy can translate to improved refractive results that are closer to intended refractive target.
Batlle JF, Feliz R, Culbertson WW. OCT-guided femtosecond laser cataract surgery: precision and efficacy. Association for Research in Vision and Ophthalmology Annual Meeting. A4694 Poster #D633. Fort Lauderdale, FL; 2011. www.arvo.org
These results reveal that femtosecond lasers significantly reduce the amount of phacoemulsification energy needed for removal of cataracts of different grades.
Edwards K, Uy HS, Schneider S. The effect of laser lens fragmentation on use of ultrasound energy in cataract surgery. Association for Research in Vision and Ophthalmology Annual Meeting. A4710 Poster #D768. Fort Lauderdale, FL; 2011. http://www.arvo.org
This paper demonstrated that significant reductions in utilized phacoemulsification energy can be achieved with the application of femtosecond LLF.
Edwards KH, Frey RW, Tackman RN, et al.
Clinical outcomes following laser cataract surgery. Invest Ophthalmol Vis Sci 2010; 51:E-Abstract 5394.
This study involving 60 eyes that underwent laser cataract surgery reported absence of adverse outcomes following laser cataract surgery. There were no differences in postoperative intraocular pressures and corneal thickness compared with conventionally treated eyes.
Dalton M. Bringing new technologies into the fold. Laser assisted cataract surgery. EyeWorld 2011; 16:30–31.
This article provides survey results from 1047 ophthalmologist regarding their opinions and concerns about adoption of femtosecond cataract surgery.
Passut J. Rules on how to charge for femto procedure get muddied, some say. EyeWorld 2011; 16:36–38.