This editorial in the August issue of the American Journal of Ophthalmology considers the role of femtosecond laser-assisted surgery. The author, David B. Glasser, MD, advocates that we should be asking whether it improves outcomes and at what cost.
He concludes that while current data does not indicate that the femtosecond laser is cost effective or superior to other technology, history shows that outcomes and efficiencies improve and complications decrease as successful new technologies mature. Equipment costs often fall with improved manufacturing methods and efficiencies-of-scale associated with widespread adoption of new equipment.
He notes that in the same journal issue, a study compared outcomes and costs of femtosecond laser-assisted DSEK with standard DSAEK and PK up to 12 months after surgery. The study's authors found that femtosecond-assisted DSEK is not cost-effective compared to DSAEK or PK, even though it is clinically effective.
Dr. Glasser also notes that early reports of femtosecond laser-assisted PK and anterior lamellar keratoplasty promised reduced astigmatism and increased wound integrity. Although improvement in acuity is more rapid and sutures are typically removed earlier (or may even be unnecessary) after femtosecond laser-assisted keratoplasty, no significant long-term differences in acuity or astigmatism have been demonstrated. However, there have not yet been any clinically meaningful controlled studies of long-term wound integrity.
He says there is even less data regarding femtosecond laser-assisted cataract surgery. While capsulotomy can be done with extreme precision, whether this results in more predictable effective lens position and more accurate IOL calculations remains to be seen. A precise capsulotomy may be important for proper centration and function of some multifocal and accommodating IOLs, but there have been no prospective clinical comparisons between laser and manual capsulotomies. The lens nucleus can be pretreated with the laser, but claims that this reduces complications remain speculative, with comparisons available only to historical controls.
Exceptionally precise arcuate corneal incisions for correction of astigmatism can be created with the femtosecond laser. However, there are no controlled, prospective studies comparing the predictability and stability of astigmatism reduction or costs of femtosecond arcuate incisions to either manual keratotomy or toric lens implantation.
Dr. Glasser says we must avoid the temptation to adopt new technologies before they are proven, based on a promise of improved outcomes or driven by financial considerations. However, once clinical investigators have demonstrated better outcomes and greater efficiencies in well-controlled clinical trials, we can reap the benefits promised by femtosecond laser technology.