Femtosecond Laser Cataract Surgery

The American Society of Cataract and Refractive Surgery (ASCRS) conference was in San Diego last week, and most of the hype and excitement was centred around Femtosecond Laser-Assisted Cataract Surgery. Although only one machine is in commercial use in the USA (the LenSx), the marketing drive is in full swing and this is set to continue, as three other companies are readying to launch their machines over the next 12 months (OptiMedica’s Catalys, Lensar, and Technolas Customlens from Germany). Alcon recently bought LenSx for more than $360 million, so it’s unsurprising that they’re trying to push home the advantage of being first on the market.

I went to an event in San Diego presented by Alcon in which a packed theatre was wowed with a laser light show before being shown videos of the femto in action, with commentary from five prominent American surgeons. Although only two of the five surgeons have the laser in their operating theatres and fewer than 1000 patients worldwide have had the surgery, the consensus was that this is the biggest advance in the safety and efficacy of cataract surgery to come around in 2 decades. Strong stuff. Are they right?

Well, it’s simply way too early to judge. Certainly, the technology in the femto systems is amazing. They can cut extremely precise wounds, and cut perfect repeatable circular openings in the 20-micron anterior lens capsule (capsulotomy) every time. This precision, greater than can be performed by any surgeon’s hands, may ultimately prove to improve visual outcomes, but so far there is no direct evidence that this is the case. Likewise, the implications for safety are all indirect and speculative, and unproven.

Femtosecond lasers were introduced into refractive surgery around 10 years ago. After a decade, they still haven’t supplanted steel blades for all patients or all surgeons, despite their stated benefits. It’s now recognized that in some settings they are safer and reduce complications, but that they also introduce different complications. Femto technology is not cheap to purchase (around $500 000 up front for the machine) or to use (companies charge a fee-per-use, known as a “click fee”), and they take significantly longer. All of this means that femto-assisted cataract surgery will be substantially more expensive than current state-of-the-art cataract surgery. 

Will it be safer? In the hands of an experienced surgeon modern cataract surgery is amongst the safest medical interventions ever devised. It will take some time and a lot of data before anyone can say that the supposed advantages of femtosecond laser cataract surgery are real, rather than imagined. There is no femto cataract laser in Queensland yet. I’m looking forward to seeing more data on safety and efficacy, and to trialling the femto when it becomes available in Brisbane.

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