A femtosecond laser goes mobile, enhancing speed, workflow, and patient satisfaction

New technologies help us continually improve patient care. Among the technologies we have introduced over the years in my high-volume surgical practice are a range of femtosecond lasers for cataract, keratoplasty, and a variety of corneal applications. All of the systems have helped us produce good surgical outcomes, and each one has offered different advantages for surgeons.

A few months ago, we purchased the Femto LDV Z8 (Ziemer) mobile femtosecond laser. In addition to its excellent clinical capabilities, including integrated OCT and a high-definition camera for clear surgical planning, it offers the advantage of portability to enhance the experiences of surgeons and patients.

We are all trying to achieve new levels of accuracy in refractive cataract surgery and other procedures. When I look back at the reasons some of my colleagues avoided femtosecond lasers, I think this particular device eliminates many of them, so more of us can start using the technology, which I believe is best for our patients and ourselves. This laser’s advantages will help more surgeons feel comfortable using a femtosecond laser and incorporating it into their workflow without adding time or making patients move between rooms during surgery. In my experience, it is relaxing to use this device, and everything turns out the way I want.

Safe, Accurate, and Precise

As good as we are, the laser is better. I use the femtosecond laser for LASIK because it makes beautiful flaps. For astigmatism correction, the arcuate incisions are highly accurate, smooth, and open with no bridges, so no manipulations are required. For cataract patients, the device produces exceptional results. I put it on a patient’s eye, scan, and treat, and I am in the eye performing cataract surgery in 2 to 3 minutes. Capsulotomy is perfectly round and centered and sized correctly to cover the lens implant.

The Z8 is particularly exciting for fragmentation. The low pulse energy allows me to cut from the lens up, as opposed to from the capsule down. If I did that with a higher-energy laser, I would damage the posterior capsule. Using the Z8, I cleanly separate the lens before opening the capsule, and then I do corneal incisions and capsulotomy at the end. Lens fragment separations are well defined, and cortical cleanup feels like manual to me, with hardly any adherence of the lens cortex to the capsule. The lens is more mobile in the bag and easier to rotate, so once I separate it, the pieces come right to the tip of the phaco. Because it is very easy to remove the lens with the phaco using much less energy, there is less trauma to the cornea. Low-pulse energy causes less disruption inside the eye with a comfortable vacuum setting, not the strong sucking pressure we used to experience. Corneas are also fairly clear the next day.

With earlier femtosecond lasers, we were limited in what we could see on the screen during surgery. With the Z8, I see fragmentation occur, so I make sure that I get the fragment I am targeting before I continue to the next stage. This makes me feel very relaxed and confident during the procedure. This is also a safe, seamless way to remove the cataract for patients who are nervous or squeamish during surgery.

For surgeons who have a LASIK suite near their OR, this device can be wheeled back and forth and utilized for advanced femto flaps, designed per the physician’s accurate specifications for depth, size, edge angles, and centration. I have been using the Ziemer femto technology for flaps for 10 years, and it has been a consistently great workhorse, with mild OBL (gas bubbles), and easy flap lifts. With the touchscreen, the centration has become significantly easier and just about foolproof.

Mobile and Workflow-friendly

Because the Z8 system is mobile and maneuverable, it changes the facility’s requirements for a laser, the femtosecond laser surgical workflow, and the patient experience. The small footprint and articulating arm make it easy to fit into small suites that could not accommodate a larger laser.

In addition, we can move it between three operating rooms as needed, or we can keep it in one room on a surgery day. Other femtosecond lasers can slow patient flow when they're housed in one operating or another location; we would take a patient to the laser, where there might be waiting time, and then take him back to another room for his procedure. Now, instead of moving patients to a laser in another room, we move the laser to the patients. As a result, time is no longer an issue for using the femtosecond laser.

Also, because the femtosecond laser is in the operating room, it can be draped sterilely. With this in mind, I knew the first day I got the system that I would use it to create a continuous flow experience. I use the laser, turn, position the microscope, and perform surgery, adding only 2 to 3 minutes to a procedure. By the same token, I can also enter the eye in the sterile environment, insert a pupil ring, and then use the laser, if needed.

The patient experience with the Z8 is the best I have seen. When patients don't have to move, they have less time to get nervous. Patients receive a little sedation, they feel comfortable, and we perform the entire procedure in one place. From start to finish, the whole experience is faster than either manual incisions or other femtosecond options. We compared patient satisfaction surveys for people moved to a laser and those treated with the portable laser, and they liked the Z8 much better. They no longer have to wait between steps, and, as a result, they don't perceive this as two procedures.

The Future of Femtosecond Lasers

Could I treat patients without this kind of femtosecond laser? I still do on occasion when patients don't choose it, but I am so happy when I can use it because it makes it much easier to achieve good clinical outcomes and patient satisfaction, and it provides a better experience for me.

As other surgeons adopt this technology, I think they will feel as I do — that it is indispensable in our practices. Patients want us to use state-of-the-art technologies on their eyes. When a technology supports top outcomes — while having positive effects on workflow and satisfaction — I am happy to oblige them. ■