Eyeworld Daily News

EW SHOW DAILY 48 Meeting Reporter Sunday, May 7, 2017 by Vanessa Caceres EyeWorld Contributing Writer capsulorhexis, fragmentation, cor- neal primary and arcuate incisions with the laser, but focus on only one or two of these initially. John Berdahl, MD, Sioux Falls, South Dakota, addressed the use of the femtosecond laser with more difficult cases, including those with loose zonules, dense cata- racts, endothelial compromise, and capsular issues. He shared the story of treating a 12-year-old boy with a ruptured capsule after he was hit in the eye with a stick 2 weeks earlier. His vision was hand motions. After surgery, "his mom went from freak- ing out to happy," he said. Richard Tipperman, MD, Phil- adelphia, discussed the financials involved with FLACS, noting that most lasers cost between $400,000 and $500,000 and have a service fee of 10% of that cost each year. There are also disposable equipment costs of about $350 to $450 a case. Sur- geons will have to do the math to see if purchasing the laser works for them but should keep in mind that the laser tends to attract additional cases from other surgeons. Patient education is also part of the mix so they are aware of the laser's benefits. "We've found that 'pre-counseling' during biometry is helpful and makes the decision less stressful for patients," Dr. Tipperman said. EW Editors' note: This event was supported by educational grants from Alcon (Fort Worth, Texas), Bausch + Lomb (Bridge- wood, New Jersey), and Johnson & Johnson Vision (Santa Ana, California). F emtosecond laser-assisted cataract surgery (FLACS) has come a long way in the past 7 years—still, surgeons con- tinue to need guidance on how to incorporate it into practices, said Eric Donnenfeld, MD, Rock- ville Centre, New York. During an EyeWorld CME Edu- cation symposium, Dr. Donnenfeld and colleagues presented pearls to help surgeons with FLACS. The event was titled "Examining LACS in Practice: The Expectation, the Re- ality, and Overcoming the Learning Curve." In the 2016 ASCRS Clinical Survey, surgeons cited the biggest advantages of FLACS as the abili- ty to create arcuate incisions and perform the capsulorhexis and lens fragmentation, Dr. Donnenfeld said. However, the biggest barriers respon- dents cited to using FLACS included cost of the technology, educating patients on the benefits, and incor- porating FLACS into the flow of the practice. Dr. Donnenfeld said he was one of the first surgeons in the world to have FLACS available and touted its current benefits, including improved accuracy, reproducibility, better arcu- ate and primary incisions, and its advantages in complex cases. Audience respondents noted that their biggest barrier to FLACS use is the financial aspects of it, and that's something that Robert Weinstock, MD, Largo, Florida, ad- dressed. Three options that surgeons have are 1) direct access, where the practice leases or purchases the fem- tosecond laser; 2) open access, where the surgeon pays per procedure at another facility (this could be a good option for low-volume surgeons or those in an academic setting, Dr. Weinstock said); and 3) roll-on/roll- off, where the laser is brought to a practice as needed. Surgeons should give some thought to the logistics involved with femtosecond laser use, Dr. Weinstock recommended. The schedule should be set so as soon as the surgeon is done with a cataract, he or she moves on to do a femto- second laser case or another cataract. "There should be no downtime," he said. He added that this setup takes a good amount of infrastructure and staff. Make sure to think of each femto use as a "case"—so even if you think FLACS cuts into your surgical volume, you have a better sense of where time is going, Dr. Weinstock advised. Dr. Weinstock also recommend- ed having a "traffic cop" at the prac- tice who watches the flow among the various surgical rooms and helps to ensure the surgeon has as little downtime as possible. When you first use the fem- tosecond laser, Tal Raviv, MD, New York, recommended choosing straightforward cases where you will get good cooperation and position- ing from patients. Keep your surgical schedule light at first to allow for more time, and start with fewer steps. For instance, you can perform FLACS tips for better patient flow and surgical results Patients who have dry eye symptoms after surgery will often blame it on the surgeon, he add- ed. "If they have dry eyes and you discover it before surgery, it's their problem," he said. "If you discover it after surgery, it's your problem, you've caused it. So you want to pay attention to that in advance." Pearls for diagnosis Surgeons shouldn't rely on signs and symptoms alone when diagnosing OSD—they need objective, evidence- based testing at the point of care, the doctors agreed. Referencing the Prospective Health Assessment of Cataract Patients' Ocular Surface (PHACO) study, Dr. Beckman noted that the majority of patients in the study were asymptomatic or minimal- ly symptomatic, but more than three-fourths of them had abnormal corneal staining. Blurred vision was more likely a symptom than burning or irritation, so these patients didn't necessarily perceive that their eyes were dry, he continued. "Cataracts aren't fluctu- ating by the minute, so it's probably tear film until proven otherwise," he said. Dr. Beckman recommended diagnosing and treating dry eye in every cataract surgery patient, regardless of whether they are symp- tomatic. Drs. Donnenfeld and Starr rec- ommended investing in the LipiScan Dynamic Meibomian Imager (Tear- Science, Morrisville, North Caroli- na), which images a patient's mei- bomian glands. Elizabeth Yeu, MD, Norfolk, Virginia, agreed, saying she does routine meibography with every cataract and LASIK patient. "If you want to invest in one technology for your office that will change the way you practice, it's the LipiScan," Dr. Donnenfeld said. "We do this on almost every patient coming in for surgery and on every patient with dry eye complains. It's a visual representation of what the patient's lids look like. When I show this to patients, they understand their disease." "The most important thing about it is showing the patient their lids and their meibomian glands, es- pecially for asymptomatic patients," Dr. Starr said. "When you show them a normal one and then you show them theirs, they get it imme- diately and they buy in to whatever you suggest as far as treatment." EW Editors' note: This event was supported by educational grants from Allergan (Dublin, Ireland), Shire (Lexington, Massachusetts), TearLab (San Diego), and TearScience. Catching continued from page 46 Dr. Donnenfeld discusses advances in FLACS over the past few years.

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