New Surgeons Ace New Technology

THE LENSX LASER IS EFFECTIVE, EVEN IN INEXPERIENCED HANDS.

By Jose de la Cruz, MD

Almost 4 years ago, the leadership in the department of ophthalmology at the University of Illinois Eye and Ear Infirmary decided to invest in a femtosecond laser for cataract surgery. Our reasoning was straightforward: We believed this technology would be key to the future of cataract surgery. As surgeons, and as educators of surgeons, we felt a responsibility to be ahead of the curve. We had already seen the benefits of using a femtosecond laser for refractive surgery, and we felt these benefits would translate well to cataract surgery and beyond.

In 2011, our academic institution was one of the first nationwide to purchase the LenSx Laser. To date, we have trained 24 residents, eight fellows and nine faculty members to perform laser-assisted cataract surgery with the LenSx Laser. Our surgeons are achieving excellent results. Furthermore, early concerns about the impact of adding a laser component to cataract surgeries, especially for surgeons in training, turned out to be non-issues or easily addressed.

Confirmed by Study

A study published in 2013 reported that early adoption of femtosecond laser-assisted cataract surgery by experienced cataract surgeons at a high-volume private practice was associated with a significant learning curve.¹ Considering this information and given our mission to train new surgeons in both manual and femtosecond cataract surgery, we felt it was important to examine the safety and efficacy of the procedure when performed by neophyte surgeons.

Our retrospective, case-control study, which was independently funded, examined outcomes in femtosecond laser-assisted (n=62) and manual (n=128) cataract surgeries performed by third-year residents and fellows.² The success rate for docking the laser was 96.8%. Four posterior capsule tears and one burn wound occurred in the manual group, but these complications did not occur in the laser group. Total ultrasound, phacoemulsification, torsional and aspiration times were statistically higher in the manual cases.

Given the difference in complications and favorable phacoemulsification use profile with femtosecond laser-assisted cataract surgery, this study provides reassuring evidence that surgeons in training can perform it safely.

But Will It Slow Us Down?

One of our initial concerns was that incorporating a laser component into some of our cataract surgeries would increase procedure times and, consequently, reduce our case volume. In fact, during our first year using the LenSx Laser, our overall case volume increased. Faculty members were able to spend less time per case in the operating room with the residents, and, therefore, could book more cases per day.

Part of that efficiency came from positioning the laser so as not to create a detour. Basically, we move patients from the pre-op area, where they are lightly sedated, to the laser suite and then to the OR, which is next door. In fact, with regard to anesthesia, adding the laser component actually improved overall efficiency. For a non-laser cataract case, the anesthesia provider stays with the patient from the pre-op area to the operating room, where the anesthesia team needs time to set up for the case while we wait. For a laser case, the anesthesia provider leaves us at the laser room, proceeds directly to the operating room to prepare for the patient and is ready for us when we arrive.

We have one LenSx Laser, and usually two or three operating rooms are available to us. Most of the time, we use one operating room, but if we use two, we can use the laser to feed patients to the different rooms. In fact, the limiting factor isn’t the laser but the surgeon and the time required to move patients in and out of the room.

Speaking for myself, if I use more than one operating room, I try to group some laser cases together and schedule one non-laser case in between to allow time for staff to clean the room. In general, however, I use one operating room and group all of my laser cases together.

Control Builds Confidence

The LenSx Laser has many safety components that ensure consistency from case to case. Surgeons can be confident that fragmentation, if set up properly, won’t harm the posterior capsule. All of these features, both before and during surgery, build confidence. The ability to visualize the anterior segment with OCT imaging as well as being able to modify the positioning of the wounds, the arcuate incisions, the capsulotomy or the fragmentation patterns on the fly adds an additional level of safety and precision.

Return on Investment

Certainly, the cost of adding a femtosecond laser for cataract surgery isn’t a minor consideration, but rather than dwell on how to pay for the laser, we focused on the long-term rewards. Our main goal was to incorporate this new technology into our training, so we could offer the most advanced cataract surgery as possible. Becoming proficient with the latest technology also enhances the resumés of the residents who graduate from our department. They can show that they’ve mastered the basics and beyond. In fact, the graduating residents and fellows comment that during their job search, the fact that they already have experience with laser cataract surgery made them more appealing to potential employers.

We also felt confident that offering laser-assisted cataract surgery would take our institution to a higher level. And that is happening. People seek out our clinic because of the new technologies we offer. As a result, both our case volume and our implantation rate for advanced-technology IOLs have increased as the level of predictability and reproducibility increased with the LenSx Laser.

Advanced-technology IOLs

Our use of advanced-technology IOLs, both toric and multifocal, along with arcuate incisions has skyrocketed for residents and faculty who are using the LenSx Laser. Our rate has increased from about 20% for non-laser procedures to almost 60% with the laser. In my opinion, our surgeons are offering these options more frequently because they have a high level of confidence in their ability to control outcomes when using the laser. For example, we know lens centration affects the performance of a multifocal IOL. With the laser, we can precisely control the size and position of the capsulotomy to ensure proper centration.

Rapid Advancements in Technology

Alcon has impressed us with how quickly it incorporates advancements into the LenSx technology. Within months of installing the laser, we received a redesigned patient interface to facilitate stable and reproducible capsulotomies with no distortion of the cornea.

Our laser-assisted cataract surgeries are performed quickly, precisely and with less energy in the eye. The entire laser treatment — incisions, fragmentation and capsulotomy — is completed in most cases in less than a minute. We’ve become comfortable and efficient. We just dock, deliver and we’re out.

There was a learning curve as we became accustomed to the technology, but we’re happy that we purchased the LenSx Laser. Being early adopters, we’ve been part of the innovation process, making recommendations for improvements. We’ve seen a quick progression of improvements in speed, efficiency and robustness of the technology. ■

References

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