FEMTO FACTOR

Seeing is believing

A laser-assisted cataract surgery demonstration is powerfully persuasive.

By Scott LaBorwit, MD

Next month will mark my third year using the femtosecond laser for cataract surgery, and it’s a commitment I’ve never regretted. Ophthalmologists who have not yet made the transition to laser-assisted cataract surgery (LACS) often ask me to demonstrate the benefits of the femtosecond laser or explain why it is superior to traditional cataract surgery alone. I’ve even been asked to let them comb through my charts to examine outcomes, or to develop a white paper they can review in hopes of debating the study design. Let me say that while white papers are great, sometimes there is just no substitute for seeing a technology in action with your own eyes.

ITS POTENTIAL IS OBVIOUS

Putting myself in their “show-me” shoes, I realize that for me the decision was pretty simple. Although I hadn’t read a single study to support use of the technology, I knew early on that I would choose femtosecond laser surgery for myself, or a family member, if we were to need cataract surgery. Thus I felt compelled to offer LACS to my own patients.

When you learn about LACS, or better yet observe a procedure, it is easy to see its potential. You can well imagine how the imaging would allow the surgeon to more precisely manage astigmatism by cutting to 85% depth of the patient’s OCT imaged cornea at the 9-mm optical zone.

The fact that the surgeon can open these incisions later to titrate refractive outcomes is another advantage. A consistent rhexus size and location may allow for more effective lens positioning. It may allow the surgeon to more effectively adjust the A-constant to assist in future IOL selection. What’s more, I have found that laser cuts based on cataract imaging typically reduce total ultrasound in the eye.

In case these advantages aren’t convincing enough, there are more to consider — such as knowing exactly how deep you can sculpt into the lens due to knowing the OCT image size, and feeling confident that you’re still 500 microns above the posterior capsule if you can still see laser cuts in the deep lens. Additionally, consistency in the primary incision (on a specific axis, and of specific length) allows for a better understanding of the impact on postoperative astigmatism.

These initial reasons compelled me to offer LACS to my patients, even though my confidence in the technology and its potential impact on outcomes was based more on its promise than on scientific evidence available at the time. Three years ago, this was a tremendous risk for a surgeon to take. However, I simply believed in the technology. I know that over the years the rewards have been exponential for my patients, practice and surgical techniques.

FROM SKEPTICS TO CONVERTS

I always enjoy watching surgeons who come to my operatory to observe LACS. They typically start out with a challenging body posture and ask skeptical questions such as “How do you know this is better than traditional surgery,” or “I believe my manual ‘rhexus is as good as the laser ‘rhexus, so why do I need a laser for surgery?”

But without fail, a transformation takes place as the day goes on. Many realize they were focused only on the laser and had not considered the impact of the imaging and how it enhances the surgical technique.

They are also surprised to see how enthusiastic my patients are about having the LACS option. Watching a femtosecond laser video or reading articles while waiting for a larger randomized paper to be published is very different from seeing the full scope of LACS in action.

When I first purchased the laser, my partner, who has been practicing for more than 25 years, had no interest in the technology. A year later, after seeing several cases with excellent outcomes, he decided to invest in the laser and training. I asked him why he changed his mind, even in the absence of published proof supporting the use of the femtosecond laser. His reply was that the technology impressed him — a reason that impressed me because my partner doesn’t even use email!

He also recognized the advantage of the laser’s precision and OCT imaging when dealing with a difficult case. My partner was not doing limbal relaxing incisions before. But, now he could manage astigmatism, using the laser to perform multifocal implants.

YOU’LL WANT TO SEIZE THE DAY

The cataract surgeon waiting for a white paper proving the value of the femtosecond laser will continue to sit on the sidelines a few more years, missing out on the advantages the technology offers patients. The surgeon who includes real-world LACS observation in his investigation will soon see the many ways the laser and imaging technology enhance the procedure and provide benefits for both patients and doctors. OM

Scott LaBorwit, MD, is a principal at Select Eye Care, with locations in Towson and Elkridge, Md., and is an assistant professor, part-time faculty, at Wilmer Eye Clinic of Johns Hopkins Hospital, Baltimore. His e-mail is Sel104@me.com. Disclosures: Dr. LaBorwit is a consultant to and speaker for Alcon.