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EW SHOW DAILY 36 ASCRS Symposia Monday, May 9, 2016 continued from page 35 by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer FLACS under scrutiny, novel use of SMILE lenticules among "Best of CSCRS" T he Alliance of Cataract and Refractive Specialty Societies brought together the best presentations from the Asia-Pacific Association of Cataract & Refractive Surgeons (APACRS), the European Society of Cataract & Refractive Surgeons (ESCRS), and the Latin American Society of Cataract & Refractive Surgery (ALACCSA) for its Com- bined Symposium of Cataract and Refractive Societies (CSCRS) on Sunday morning. Is FLACS better? At the symposium, Paul Rosen, MD, Oxford, U.K., put femtosecond laser- assisted cataract surgery (FLACS) under close scrutiny to answer the question "Does femto cataract sur- gery produce better outcomes?" Dr. Rosen defined "better out- comes" by 4 criteria: lower complica- tion rate, as indicated by reductions in inflammatory mediators, capsule complications, effective phaco time, posterior capsule opacification, and lens decentration; better visual outcome, in terms of an increased number of lines gained, better un- corrected and best corrected visual acuities, reduced astigmatism, and improved patient satisfaction; cost effectiveness, with the procedure's increased cost matched by better clinical outcomes and patient qual- ity of life or a reduction in societal and patient costs relating to the health economy as a whole; and fi- nancial viability, which is dependent on the commercial environment of individual clinics. In terms of complications, FLACS did significantly reduce effective phaco time; however, Dr. Rosen said that studies have shown increased inflammatory markers, likely relating to the introduction of laser energy. Assessing outcomes, Dr. Rosen said that the EUREQUO FLACS case control study concluded that while femto patients did have less postop- erative astigmatism and surgery-in- duced astigmatism, they had worse postoperative visual acuity and post- operative complications. Moreover, more patients had a postop visual acuity that was worse than preop. In the study, FLACS did not out- perform phacoemulsification. Dr. Rosen measured the proce- dure's cost effectiveness by placing the cost against the gain in quality of life (QALY), as the incremental cost of extra QALY gained (ICER). In the U.K., he said, the ICER needs to be less than $28,000/QALY gained to be funded by the govern- ment. With estimates based on 5% visual acuity improvement—that is, 95% of eyes achieving 20/40—the ICER of femto phaco was $92,000/ QALY. In a public health care system, Dr. Rosen calculated that cost effec- tiveness could be achieved if patient throughput were to increase by 30%. Theoretically, this could be achieved by performing the femto procedure on 10 patients per hour, feeding through to 2 operating rooms. The best phaco surgeons, he said, will be more cost effective than femto phaco, with consistent quality and productivity—not just best case—being factors. In this sense, the femtosecond laser could be seen as an enabling technology; less skilled surgeons can achieve the same outcome as the best. In addi- tion, with trends showing a combi- nation of an aging population, in- creasing demand, and fewer cataract surgeons, Dr. Rosen suggested that the technology might be used as a surgical tool to drive productivity and sustainable quality. Ultimately, however, to be cost effective, clinical outcomes have to be very much better or costs signifi- cantly lower, and in order for FLACS to be introduced on a large scale, Dr. Rosen said that the procedure needs to demonstrate better clinical and refractive outcomes and patient satisfaction, reduced variability and improved reliability and reproduc- ibility, increased speed/throughput, and reduced complications. It must ultimately prove to be a benefit for the surgeon, the purchaser, the pro- vider, and the patient. Intracorneal SMILE inlays At that symposium, Sri Ganesh, MD, Bangalore, India, presented a novel approach to correcting hyper- opia in combination with collagen crosslinking to stop the progression of keratoconus. Dr. Ganesh said that refractive procedures such as PRK, intracorneal ring segments, and phakic IOLs in combination with crosslinking tend- ed to have unsatisfactory results: PRK risks further destabilization; intracorneal ring segments are attended by the risk of extrusion, perforation, migration, and infec- tion; phakic IOLs risk cataract, sec- ondary glaucoma, endothelial cell loss, and vaulting issues. His solution utilizes cryopre- served lenticules from small incision lenticule extraction (SMILE) as intra- corneal inlays. Using a punch, the lenticules are cut into a donut shape and implanted into a pocket created using the femtosecond laser. The procedure, he said, is limit- ed to mild to moderate central cones on topography, the results may be unpredictable in advanced cases, and nomograms need refinement. Nonetheless, Dr. Ganesh's approach appears to be a feasible, reversible option to treat keratoconus, poten- tially improving quality of vision by improving the corneal shape and reducing aberrations, with no risk of extrusions or infections, and low risk of allogeneic rejection. EW Editors' note: Dr. Rosen has no related financial interests. Dr. Ganesh has financial interests with Abbott Medical Optics (Abbott Park, Illinois) and Carl Zeiss Meditec (Jena, Germany). An attendee snaps some information from the Combined Symposium of Cataract and Refractive Societies. natamycin for fungal ulcers, she added. The first trial found that natamycin was more effective than voriconazole for smear-positive fila- mentous fungal keratitis, particular- ly in Fusarium cases. Within the cornea realm, many U.S. specialists are talking about collagen crosslinking (CXL), which was approved by the U.S. Food and Drug Administration (FDA) just last month, said Roy Rubinfeld, MD, Washington, D.C. The U.S. lagged behind many other nations in the world that have used CXL for several years. Dr. Rubinfeld shared findings from his research with colleagues on the use of riboflavin with CXL and the comparison of epithelium (epi)- on versus epi-off CXL. Terry Kim, MD, Durham, North Carolina, focused on tissue sealants, which he said are increasingly used, albeit sometimes in an off-label manner. One approach he has ob- served is Tisseel (Baxter, Deerfield, Illinois) for amniotic membrane transplantation in pterygium sur- gery. However, Tisseel is also used during lamellar keratoplasty, he said. A newer product, ReSure (Ocular Therapeutix, Bedford, Massachu- setts), is approved by the FDA to seal clear corneal incisions after cataract surgery, Dr. Kim said, pointing out that the product is not the same as a glue. EW Editors' note: Dr. Asbell has financial interests with Oculus. Dr. Kim has financial interests with Alcon (Fort Worth, Texas), Allergan (Dublin), Bausch + Lomb (Bridgewater, New Jer- sey), and other ophthalmic companies. Dr. Rubinfeld has financial interests with CXLUSA (Bethesda, Maryland). Dr. Rose-Nussbaumer has no related financial interests.

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