Eyeworld Daily News

EW SHOW DAILY 4 Wednesday, May 11, 2016 FLACS vs. phaco or FLACS and phaco? by Chiles Aedam R. Samaniego EyeWorld Asia-Pacific Senior Staff Writer Elsewhere Providing an international perspec- tive, Ronald Yeoh, MD, Singapore, said that by 2016, Singapore—with its relatively small "dot in the ocean" population of about 5 mil- lion—had a total of 6 femto laser cataract machines. In addition, he said that the market is being driven somewhat by competition in China. All of which suggests that, whatev- er its final, "objective" value, the technology was being embraced in the region. For his part, Dr. Yeoh initially asked 3 basic questions to consider why he should adopt the technol- ogy: Is it better? Is it safer? Is it cheaper? Citing various published studies and his own experience, he said it is not proven to be better, is only arguably safer—particularly for its utility in traumatic cases—but is certainly not cheaper. Inclusive perspective All that said, in the end, Dr. Slade and Dr. Yeoh independently came to the same conclusion—that perhaps pitting phaco against FLACS was the wrong way to think about things. Citing how, according to the American Academy of Ophthalmol- ogy, the "pivotal trial" that closed the case against ECCE only came 34 years after the introduction of phaco, as well as how the debate between phaco and manual suture- less small-incision extracapsular cataract surgery continues, Dr. Slade wondered if surgeons arguing over FLACS on both sides weren't, after all, missing the point? "This is a surgical technique, not 2 cancer drugs we are comparing for efficacy," he said. Dr. Yeoh came to a similar con- clusion, arguing that, perhaps, pha- co and FLACS should be considered complementary technologies—but with a caveat. "If average surgeons can achieve better results with femto than phaco, then surely FLACS has a place provided the cost issue is addressed," he said. EW Editors' note: Dr. Slade has financial interests with Alcon (Fort Worth, Tex- as). Dr. Bakewell has financial interests with Abbott Medical Optics (Abbott Park, Illinois). Dr. Yeoh has financial interests with Alcon and Abbott Med- ical Optics. Dr. Yoo has no financial interests related to her comments. stamp perforations" along the edges of femto capsulotomies seen by electron microscopy—the edges of manual capsulotomies, in com- parison, are smooth. And while he said there is "no question that the roundness of the femto capsulotomy is close to perfect and consistently more round than manual capsulot- omy," he found that the size of the capsulotomy is more uniform in manual cases, and the centration is "good but not always perfect." He argued that if the capsulo- tomy is the main selling point of FLACS, then the data shows the technology wanting. Dr. Bakewell did, however, con- cede that FLACS certainly decreased effective phaco time (EPT)—an important safety consideration— and that femto incisions have better structural integrity than manual incisions. Meanwhile, femto AKs, he said, are more precise than LRIs, but not as predictable as toric IOLs. New technology might also be pushing FLACS aside. Initial data, he said, shows that the Zepto Precision Pulse Capsulotomy (Mynosys, Fre- mont, California) "creates a stronger capsulotomy than the femto and can be well centered over the visual axis at the cost of a disposable." Moreover, he said, "FLACS may be too cost prohibitive in some demographic areas to become the standard for cataract surgery." Where are we now? For a comprehensive picture of where the technology is today, Sonia Yoo, MD, Miami, enumerated the things the femtosecond laser machines can and can't do. It can do imaging, capsulotomy, fragmenta- tion, and corneal incisions; it can't do treatments through iris or sclera, treat a moving target, or treat with- out suction on the eye. Of the things femto machines can do, Dr. Yoo and the other experts at the symposium seemed most impressed and hopeful about the imaging technology that has evolved as integral to the procedure. Intraoperative imaging has devel- oped more or less in tandem with FLACS, and remains perhaps the single most promising—and useful, in the broader sense—achievement. "LASIK-like vision" following cata- ract surgery. FLACS suggested a way to po- tentially answer the question in the affirmative. In the first 5 years of the tech- nology, Dr. Slade said that he was initially impressed and motivated by the potential for perfectly shaped, perfectly reproducible capsuloto- mies. Although at the very begin- ning a full 360-degree capsulotomy —even a capsulotomy just over 180 degrees—was cause enough for excitement with the technology, by the end of those 5 years, completely free-floating capsulotomies were already the norm. If those first 5 years are all we've got to go on, he said that femto- second laser cataract technology is like digital technology to phaco's analog—"Imagine how far anything digital can progress in 5 years," he said. Contrary view In 2016, Brock Bakewell, MD, Tucson, Arizona, remains unswayed by the technology. In his experi- ence, he said, anterior capsular tears occur at a higher incidence than with his manual technique. This is in part due to the rough "postage I n February 2010, the femtosec- ond laser for cataract surgery first arrived in the clinic of Stephen Slade, MD, Houston. At the time, Dr. Slade was in a solo, referral-based, minimally marketed private practice in the pro- cess of shifting from "LASIK major, minor cataract" to "cataract major, minoring in LASIK" that had a high rate of premium IOL conversion. He was, he said, intrigued by the laser as a way to continue that pathway of growth. With this background, Dr. Slade was ideally positioned to provide an overview of femtosecond laser cataract surgery's history at a sympo- sium on "Four Years of Femtosecond Laser-Assisted Cataract Surgery" held on the morning of the last day of the 2016 ASCRS•ASOA Symposium & Congress. Five years Dr. Slade said that femtosecond la- ser-assisted cataract surgery (FLACS) was first conceived as a potential answer to the question, "Is cataract surgery good enough?" Against the background history of the then more than 20 years of LASIK, Dr. Slade's patients, wheth- er fair or not, had begun to expect Dr. Yoo discusses the development of intraoperative imaging in tandem with FLACS.

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