Femtosecond Laser Cataract Surgery in the United States.
In February 2010, my staff and I received the LenSx femtosecond laser (LenSx Lasers Inc., Aliso Viejo, CA; distributed in the United States by Alcon Laboratories, Inc., Fort Worth, TX). Since then, we have been successfully performing laser cataract surgery at our center in Huston. I believe this technology represents the perfect marriage of the cataract and refractive subspecialties. This article describes what I foresee as the femtocataract technology’s position in ophthalmology.
MEETING PATIENT DEMANDS
Each year, there are approximately 3.25 million cataract surgeries performed in the United States and around 19 million procedures worldwide. Are we delivering the level of care that patients desire with cataract surgery? Refractive surgery taught me that patients need two things to be happy: a safe surgery, and the ability to see well without glasses afterwards. Even individuals who need a complicated procedure such as a corneal transplant or riboflavin/UV cross-linking ultimately want to see perfectly without their glasses. Are we surgeons delivering on that request?
Figure X shows the 20/25 and 20/20 UCVA results from the latest FDA trial on an IOL compared with the latest FDA data on LASIK. There is a wide difference between these two procedures. It appears as though we are not giving our cataract patients the kind of UCVA that we are providing LASIK patients. Can we improve these results?
Market Scope reports that there are 7,800 cataract surgeons in the United States. Only 2,000 of those practitioners identify themselves as cataract/refractive surgeons. The rest consider themselves either cataract surgeons who do not perform refractive surgery or refractive surgeons who perform little or no cataract surgeries. Therefore, the small group of cataract/refractive surgeons has the best chance to address the disparity between the two subspecialties.
TIME AND PLACE: FITTING THE LENSX INTO THE CLINIC
We do not keep the LenSx laser in the OR, but in a separate, environment-controlled room. Both my staff and my patients appreciate the speed of the laser. The LenSx requires about 60 seconds of suction time, and it takes another 3 to 5 minutes to make the capsulotomy and fragment the nucleus. Then, we roll the patient into the OR to extract the nucleus and implant the lens. This laser cuts the length of a cataract procedure significantly.
The laser’s proprietary optical coherence tomography (OCT) imaging system lets you view the entire anterior segment as you operate the machine. The laser begins the cut for the capsulorhexis posteriorly, then it penetrates into the anterior chamber to fracture the nucleus. It leaves a beautiful, 3-dimensional (3-D) cut in the nucleus. The LenSx can also make secondary and astigmatic cuts in the cornea. Indeed, the laser is a “knife” that you can preprogram to make any type of cuts—cylinders, slits—only programming time is the limit.
SURGICAL ADVANTAGES OF THE LENSX LASER
The LenSx femtosecond laser can help us improve the quality of cataract surgery at least two ways. First, the laser enables the surgeon to precisely control the capsulotomy. The human hand cannot make capsulotomies as perfectly shaped or reproducible as a femtosecond laser. The laser also provides amazing control over the capsulotomy’s centration, shape, and diameter, and you can achieve the exact same configuration every time. The capsule’s opening is very important in determining the effective lens position. A smaller opening will induce more contraction, and a larger opening will result in the opposite. We can measure the corneal curvature and the axial length, but we cannot predict the IOL’s final resting position. With the LenSx laser providing a consistent capsulorhexis, we can predict the effective lens position much more accurately. Just by switching to this device, I have reduced my standard deviation of spherical component considerably. Simply put, this laser makes lens implantation more predictable.
The LenSx femtosecond laser also improves the management and correction of astigmatism. What if we could make limbal relaxing incisions (LRIs) in the same way we treat astigmatism with an excimer laser? The LenSx has preprogrammed astigmatic cuts that make this procedure simple. It allows us to place LRIs wherever you wish, whatever size, and configuration. We are developing a specific nomogram for corneal astigmatic incisions based off of Eric Donnenfeld, MD’s excellent nomogram with outstanding results.
Figure X shows the LenSx laser performing nuclear cracking. Colleagues have asked me how this procedure will impact phacoemulsification. I think it is the perfect partner for phacoemulsification, because it will allow us to optimize our phaco machines and our techniques. We can still use our preferred technique to remove the fragmented nucleus.
Another advantage this device offers is with removing cortex. We can start the capsulorhexis behind the capsule and then come up through it and bypass the cortex. This approach provides a distinct cut cortical edge all the way around the capsulorhexis, which makes removing it a little bit easier and more efficient.
Again, with the ability to size and locate the capsulorhexis where we want it, we should be able to customize this step to individual IOLs in the future. Perhaps certain implants will be centered anatomically, by line-of-sight, or on the dilated pupil. Because the LenSx laser can standardize these steps, we can track our results with various techniques. All of these capabilities will drive effectiveness in cataract surgery.
The femtocataract procedure also has exciting implications for challenging eyes, such as those with low endothelial cell counts, pseudoexfoliation, etc. I’d rather leave the zonules alone in those patients. A femtosecond-made capsulotomy on an eye with a white cataract may not require capsular dye.
SAFETY
The literature shows that refractive surgery is safer than cataract surgery, with fewer incidences of adverse events. I think the LenSx femtosecond laser can improve surgical safety and efficacy. Since using this machine, my staff and I have seen a dramatic reduction in phaco time, phaco power, and endothelial cell loss compared with historical norms that we found in literature. These findings make sense, because the femtocataract procedure reduces phacoemulsification and the number of times the surgeon enters the eye.
For now, my staff and I are concentrating on optimizing our cataract surgeries using the INFINITI Vision System with AquaLase, OZil IP torsional ultrasound (Alcon Laboratories, Inc., Fort Worth, TX), and different tips and settings. We are exploring how to adapt these technologies to use them together. For example, for soft nuclei, we can use a series of soft cylinders to liquefy the cataract and then perform I/A. In the majority of cases, we use a blend of femtosecond laser and phacoemulsification to improve our speed, safety, and outcomes.
CONCLUSIONS
I think the femtocataract procedure will bring us the efficacy and safety we want for our patients (and ourselves). In the coming years, the baby boomers—the biggest demographic group in the United States—will be moving into their cataract years. The first Boomers entered Medicare this past January 1st. These individuals will make up the majority of our patients in the future. The femtocataract technology will suit this demographic beautifully; I anticipate that baby boomers will readily adopt a more automated cataract surgery just like they have accepted all-laser LASIK. I suggest that we all get ahead of this curve.
Stephen G. Slade, MD, is a surgeon at Slade and Baker Vision in Houston. He serves as the medical director for LenSx Lasers Inc., and he is a consultant for Alcon Laboratories, Inc. Dr. Slade may be reached at (713) 626- 5544; sgs@visiontexas.com.
For more information, see these websites:
Dr. Stephen Slade MD was the first surgeon in the United States to perform LASIK eye surgery and also has the longest experience with Bladeless LASIK or LASIK performed with two lasers including one to make the flap.
Dr. Stephen Slade MD has extensive experience and has performed LASIK and other types of refractive surgery on more than 25,000 patients from Houston and around the world.
More recently, Dr. Stephen Slade MD performed the first Laser Cataract Surgery procedure in the United States, setting a new standard in cataract care.
LASIK eye surgery pioneer Dr. Stephen Slade MD, MD, FACS is a Houston, Texas native who is a specialist in vision correction procedures.
Patients from all around the world seek the professional ophthalmology and LASIK eye surgery services of Dr. Stephen Slade MD.
Dr. Stephen Slade MD is a leading surgeon in the international community as well as in the Houston LASIK community and is a member of the Optical Express International Medical Advisory Board (IMAB).
Dr. Stephen Slade MD is an active teacher of surgical techniques and has taught and certified over 8,000 surgeons in LASIK and lamellar refractive surgery.
Dr. Stephen Slade MD‘s experience with lamellar refractive surgery began in 1980 with epikeratophakia, followed in 1983 with myopic keratomileusis.
Dr. Stephen Slade MD is a native Houstonian and attended Tulane University and the University of Texas Medical School with a final, elective year spent at Guy\’s Hospital, London, graduating Summa Cum Laude, with highest honors.
Dr. Stephen Slade MDcompleted a residency at the LSU Eye Center in New Orleans and Fellowships in corneal surgery at Baylor College of Medicine in Houston and in New York on Project ORBIS.
Dr. Stephen Slade MD is highly regarded among other Ophthalmologists and is considered to be the “Surgeon\’s Surgeon” as over 450 of his fellow eye surgeons have chosen him to perform their own eye surgery.
Dr. Stephen Slade MD is an active researcher and the United States Medical Monitor for several new technologies including the B&L Technolas and ALCON Excimer Laser Custom Vision Clinical Trials.
Dr. Stephen Slade MDhas received numerous awards including 12 named lectures, Refractive Surgeon of the Year, two China Service Medals and the Summit Technologies Pioneer of Refractive Surgery Award.
Dr. Stephen Slade MD is a Fellow of the American Academy of Ophthalmology and the American College of Surgeons.
Dr. Stephen Slade MD performed the first LASIK in the United States. Later he performed the first Custom LASIK ablation based on topography in the United States and has remained on the cutting edge, having the first and longest experience with all laser LASIK, accommodating intraocular lenses for cataract surgery (crystalens) and implantable corneal contact lens.
Dr Stephen Slade was a lead investigator and presented the data to the FDA for panel approval for both the crystalens and the implantable contact lens, and as part of the trial, he implanted the first intraocular lens for presbyopia in North America.
In 2006 the American Academy of Ophthalmology and International Society of Refractive Surgery selected Stephen Slade MD for the 2007 Barraquer Award and Lecture, the top award in Refractive Surgery.
Dr Stephen Slade‘s peers have selected him for inclusion in “Top Fifty Opinion Leaders,” “Top Texas Doctors,” “Best Doctors,” and “Best Doctors in America.” He has also received the Honor Award of the American Academy of Ophthalmology and is a regular presenter at medical meetings where he has received several “Best Speaker” awards and has twice won First Place at the American Society of Cataract and Refractive Surgery Film Festival.
Stephen Slade MD is on several Editorial Boards including the Journal of Refractive Surgery, has produced many articles, book chapters, holds five patents or patents pending in the field and has authored five textbooks on refractive surgery. has been featured in numerous news segments aired on CBS, ABC, NBC, UPI International and PBS as well as numerous national affiliate stations.
Dr Stephen Slade has also been quoted in the New York Times, The Wall Street Journal, and Newsweek. He was the featured surgeon on the Emmy Award- winning PBS documentary “20/10 by 2010?” narrated by Walter Cronkite.
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