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Metanalysis 68,000 eyes from ECCE, ICCE, Phaco No difference in Va No difference in complications
Arch Ophthalmol. 1994;112:239-252)
12/3/2016 Saras Ramanathan, MD Associate Professor Division Chief, - - PowerPoint PPT Presentation
12/3/2016 Saras Ramanathan, MD Associate Professor Division Chief, - - PowerPoint PPT Presentation
12/3/2016 Saras Ramanathan, MD Associate Professor Division Chief, Comprehensive Ophthalmology none UCSF 1985 1994 How many of you are cataract surgeons? How many are currently performing Femtosecond Laser Assisted Cataract
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Wound Reproducibility Induced astigmatism Self-sealing Astigmatic treatment Predictability, Precision Capsulotomy Centration, Circularity,
Completeness
Lens treatment decrease US time and power Post-operative course PCO Capsule contraction Lens tilt, aberrations Learning Curve Complication rate Surgical time Cost Effectiveness Surgeon Patient Patient Satisfaction
- Self-sealing, reproducible wound with little induced astigmatism.
- Astigmatism correction should be predictable and precise
Decreased post operative
central K thickness with FLACS
Slightly less endothelial cell loss
with FLACS
Fewer Descemet detachments
with FLACS
Primary and secondary incisions
show no difference in:
Surgically Induced Astigmatism Higher order aberrations from
wound
Wound sealability
Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser- Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005 Nagy, Z et al. Evaluation of femtosecond laser-assisted and manual clear corneal incisions and their effect on surgically induced astigmatism and higher-order aberrations. J. Refract Surg 30:8 522-525 Aug 2014. 10.3928/1081597X-20140711-04
Effective treatment of low level astigmatism Studies mostly from refractive surgery literature Equivalent to toric IOL Await nomograms specificially for laser AK / FLACS
Day, et al. Correction of astigmatism at the time of cataract surgery. Curr OpinOphthalmol, 20 (2009), pp. 19–24 Hayashi K et al. Effect of astigmatism on visual acuity in eyes with a diffractive multifocal intraocular lens. J Cataract Refract Surg. 2010 Aug;36(8):1323-9. doi: 10.1016/j.jcrs.2010.02.016. Yoo A. Femtosecond Laser-assisted Arcuate Keratotomy Versus Toric IOL Implantation for Correcting Astigmatism. J Refract Surg. 2015 Sep;31(9):574-8. doi: 10.3928/1081597X-20150820-01.
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Effect on US time and power with secondary effect on cornea Other Intraoperative factors
Increased posterior capsule
rupture
Increased anterior capsule tags
and tears
Increased prostaglandin release Unchanged or slightly increased
case time
Decreased phaco time Decreased phaco energy Slightly protective to
endothelium
Decreased post op central
corneal thickness
Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123,
- no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005.
Abell RG et al. Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single center. J Cataract Refract Surg. 2015 Jan;41(1):47-52. doi: 10.1016/j.jcrs.2014.06.025. Epub 2014 Nov 11.
Centration, Circularity, Completeness Implications for capsule contraction and PCO
Capsulotomy slightly more circular, centered Strength comparable to manual capsulorhexis Better IOL overlap Slightly less PCO
Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005 Kovács I, Nagy ZZ et al. The effect of femtosecond laser capsulotomy on the development of posterior capsule
- pacification.J Refract Surg. 2014 Mar;30(3):154-8. doi: 10.3928/1081597X-20140217-01.
Grewal DS et al. Femtosecond laser-assisted cataract surgery--current status and future directions.Surv Ophthalmol. 2016 Mar-Apr;61(2):103-31. doi: 10.1016/j.survophthal.2015.09.002. Epub 2015 Sep 26.
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Less lens tilt Decreased AC depth variability Some studies suggest
decreased internal aberrations,
- thers show no difference
No diffce in UCVa with premium
IOLs
Toric, multifocal have equal UCVa
with FLACS vs. Phaco
Toto, L. et al. Postoperative IOL Axial Movements and Refractive Changes After Femtosecond Laser-assisted Cataract Surgery Versus Conventional Phacoemulsification. J Refract Surg. 2015; 31(8):524-530. doi:10.3928/1081597X- 20150727-02 Lawless M. Outcomes of femtosecond laser cataract surgery with a diffractive multifocal intraocular lens. J Refract Surg. 2012 Dec;28(12):859-64. doi: 10.3928/1081597X-20121115-02.
No difference post-op visual acuity regardless of IOL type Toric, multifocal, monofocal Corrected, uncorrected Va no different from phaco alone
Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005 Ewe SY, et al. A Comparative Cohort Study of Visual Outcomes in Femtosecond Laser-Assisted versus Phacoemulsification Cataract Surgery. Ophthalmology. 2016 Jan;123(1):178-82. doi: 10.1016/j.ophtha.2015.09.026. Epub 2015 Oct 31.
Under the least advantageous scenario our surgeon has decided to purchase the
laser himself or herself, convinces 30% of his or her patients to pay for the laser, and experiences a 30% decline in productivity because of the laser. This results in 105 cases generating an additional US $102 375 of revenue, but with additional costs of US $164 010, a net loss of US $61 635. Clearly, this is not a sustainable situation and suggests that lone practitioners may not find FLACS a viable
- procedure. Certainly, the situation improves if our surgeon uses a shared laser
with a total volume of 1000 cases per year. The total cost for 105 cases falls to US $54 810, netting the surgeon US $47 565. We think this is probably the most like general scenario, larger groups of average volume surgeons banding together to purchase a laser.
Bartlett JD1, Miller KM. The economics of femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol. 2016 Jan;27(1):76-
- 81. doi: 10.1097/ICU.0000000000000219.
OWN LASER SHARED LASER # FLACSCASES PER YEAR 105 105 (1000 cases total) REVENUE $102,375 $102,375 COSTOF LASER $164,010 $54,810 ANNUAL PROFIT OR (LOSS) ($61,635) $47,565
Bartlett JD1, Miller KM. The economics of femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol. 2016 Jan;27(1):76-81. doi: 10.1097/ICU.0000000000000219.
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“Laser cataract surgery, irrespective of potential improvements in visual acuity outcomes and complication rates, is not cost effective at its current cost to patient when compared with cost- effectiveness benchmarks and other medical interventions, including PCS. A significant reduction in the cost to patient (via reduced consumable/click cost) would increase the likelihood of LCS being considered cost effective.”
Abell RG, Vote BJ. Cost-effectiveness of femtosecond laser-assisted cataract surgery versus phacoemulsification cataract surgery. Ophthalmology. 2014 Jan;121(1):10-6. doi: 10.1016/j.ophtha.2013.07.056. Epub 2013 Oct 10.
Refractive surgeons have slight advantage in learning curve After 100 cases, no difference between novice vs. experienced
surgeons in terms of complication rate
Even after 200 cases, FLACS added 5 mins intraoperatively
and 10 mins to total case time
Bali SJ et al. Early experience with the femtosecond laser for cataract surgery. Ophthalmology. 2012 May;119(5):891-
- 9. doi: 10.1016/j.ophtha.2011.12.025. Epub 2012 Feb 22.
Grewal DS, Basti S et al. Impact of the Learning Curve on Intraoperative Surgical Time in Femtosecond Laser-Assisted Cataract Surgery. J Refract Surg. 2016 May 1;32(5):311-7. doi: 10.3928/1081597X-20160217-02.
Conclusion: The frequency of major and minor complications fell sharply after the first 150 operations and was maintained. This study may provide a guide for beginning phacoemulsification surgeons and a basis for experienced surgeons to compare their performance outcomes. J Cataract Refract Surg 1998; 24:1390-1395
FLACS Better FLACS = Phaco Phaco Better Wound Lower US time and power Endothelial cell loss Wound sealability Astigmatism Equal to toric IOL Capsule IOL Coverage by capsule Lens tilt Centration and circularity Higher order aberrations Anterior and posterior capsule tear Intra-op Meiosis/prostaglandin Procedure time/OR time Post-op Post operative cental K edema Toric and Multifocal no difference in Va Cost Cost to MD Cost to patient Satisfaction Post operative visual acuity Learning curve (?)
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FLACS Better FLACS = Phaco Phaco Better Wound Lower US time and power Endothelial cell loss Wound sealability Astigmatism Equal to toric IOL Capsule IOL Coverage by capsule Lens tilt Centration and circularity Higher order aberrations Anterior and posterior capsule tear Intra-op Meiosis/prostaglandin Procedure time/OR time Post-op Post operative cental K edema Toric and Multifocal no difference in Va Cost Cost to MD Cost to patient Satisfaction Post operative visual acuity Learning curve (?)