New data on femtosecond laser assisted cataract surgery continued to amaze at the 2013 Congress of the European Society of Cataract and Refractive Surgeons. However, still missing are data that prove it’s better than standard phacoemulsification.
Professor H. Burkhard Dick, MD, chairman of the University Eye Hospital Bochum in Germany, presented data showing the benefits, including decreased effective phaco time, less ultrasound energy, less endothelial cell loss, less bag shrinkage, and less corneal shrinking.
Of his last 400 surgeries, 99 percent required no ultrasound energy at all, just aspiration. The three cases that required ultrasound were grade 4 cataracts. In standard cases, he finds OVDs unnecessary.
But what impact does femtosecond precision have on visual outcomes? Oliver Findl, MD, MBA, believes there is no benefit in terms of improved visual outcomes. In a debate symposium at the ESCRS meeting, Dr. Findl countered with a study he recently conducted showing that a perfectly sized rhexis actually has little effect on IOL positioning.
“With modern IOLs in healthy corneas, there’s no impact,” Dr. Findl said. “It’s fascinating technology, but is makes very little difference to the patient.”
Dr. Dick believes the data will come. Today’s IOLs are not designed for the perfect capsulotomy. He adds that challenging cases, especially Marfan’s, intumescent cataracts, and pediatric cases, will see a real benefit from femtosecond laser.
David F. Chang, MD, clinical professor at the University of California, San Francisco, believes the technology is here to stay. The only question is how it will shape the future.
“There’s no question that it’s amazing technology. It’s here to stay, without a doubt. But what percentage of our patients will be using it?” Dr. Chang said. “Will it take hold for a majority of our patients?”
Dr. Chang drew a comparison with multifocal IOL technology. Introduced in 1997, it was predicted to transform the IOL market. Sixteen years later, the technology is here to stay but it only accounts for about 7 percent of the market. A recent study of ASCRS members showed that 7.9 percent of its members implant multifocal IOLs, compared with 18.9 percent who prefer monofocal monovision for presbyopia correction.
While femtosecond technology is exploding, he said, there are no data showing it is improving refractive outcomes. He said he hopes physicians aren’t jumping in to femtosecond cataract surgery for greed or fear of losing patients.
Just back from Ethiopia where he helped conduct 750 cataract surgeries over a period of five days, he noted that this is where the world “needs a paradigm shift” to serve the millions blinded needlessly from cataracts.
Affluent patients willing to pay extra are adopting the technology today, regardless of outcomes data. As for predicting the future of femtosecond cataract surgery, Dr. Chang turned to a theory from the business world. He said Clayton M. Christensen’s ideas about disruptive innovation may apply. New, innovative ideas that displace earlier technology sometimes do so in ways that the market does not expect, typically first by designing for a different set of consumers in a new market and later by lowering prices in the existing market.
“This is how progress occurs,” Dr. Chang said. “Cellular phones were once confined to Mercedes and BMWs. Now the technology has opened up to everyone.”
Regardless of sides taken in the debate, the panelist agreed they'll still be talking about it for the next 10 years.