Cataract & Refractive 2011

Reviewed by Professor Jorge L. Alió, Dr Alessandro Franchini, Dr Günther Grabner and Dr Erik Mertens

This year has seen an exciting development in the field of cataract and refractive surgery — femtosecond laser cataract surgery (FACS). With a few systems already on the market offering FACS there have been many results and presentations to enjoy at the years' events. However, FACS was not the only innovation making waves this year. Anyone attending the shows during the course of 2011 may have been fortunate enough to learn about the new options for presbyopic patients and as ever premium IOLs were still dominant on the exhibition floors and in sessions. To find out a little more about the exciting developments and what we can look forward to in the future, we spoke with experts in the field, Professor Jorge Alió, Dr Alessandro Franchini, Dr Günther Grabner and Dr Erik Mertens.

Establishing FACS

"The most important innovation of the year is to establish FACS as a consistent and stable procedure in my practice," said Professor Alió, professor and chairman of Ophthalmology at Miguel Hernandez University, Alicante, and medical director, Vissum Corporation, Alicante, Spain. "The access of FACS has been available since September in Vissum, Alicante, and is indeed opening a new era in my cataract surgery."

This has certainly been reflected in the opinions and presentations given at the annual events, including one of the Main Symposia at the European Society of Cataract & Refractive Surgeons (ESCRS) Congress, which was chaired by one of our reviewers, Dr Grabner (University Eye Clinic Salzburg, Austria). "Certainly understanding what drives the craze with FACS and into which directions cataract surgery will develop has been exciting," he agreed. "The biggest opportunity for me has been to be actively involved in some clinical research that will have direct implications for treatment of astigmatism simultaneous with FACS."

Sidebar 1: Currently available FACS technology.

Dr Mertens (Antwerp Eye Center, Antwerp, Belgium) also supported the opinion that FACS has been vital to 2011. "For me, the biggest innovation and opportunity of the year has been the femtosecond cataract surgeries I did with the new VICTUS platform," he said. (For more information on the platforms available please see Sidebar 1.)

Beginning of a new era

However, with the new laser procedure being capable of performing multiple steps in cataract surgery, what impact will the advent of increasing numbers of FACS platforms have on the industry, for example phaco? In some peoples' opinions this is not a point of concern... yet.

"Phaco is here to stay for a long time as it is still needed in the majority of cases," asserted Dr Grabner. "There will be the larger centres performing FACS and growing and eventually most of the smaller units will be losing business... but this may take years." Dr Mertens supported this opinion completely. "This technology is still very young," he said. "The technology will become more readily available to more surgeons, dropping the cost and peaking the interest of more patients. However, phaco is a very good technique and will be around for many more years to come."

"It is the beginning of a new era," added Prof. Alió. "Phaco will be affected as simplified phaco machines will be only needed to end cataract surgery."

In contrast to the other experts, Dr Franchini (University of Florence Eye Institute — Azienda Ospedaliera Careggi, Florence, Italy) has a more tentative approach to FACS. "This new generation of femtosecond lasers that is emerging seems to be able to perform corneal surgery and the crucial steps in cataract surgery with safety and refractive precision. Still we don't know for sure that this new generation of femtosecond lasers for cataract surgery is one of the most important innovations at the beginning of the century, but it is surely the most exciting for the future," he revealed. In Dr Franchini's opinion the industry is close to an epocal novelty in the field of phacoemulsification devices. "After 50 years in which ultrasound has represented the gold standard for cataract extraction a new energy source seems capable of outdoing its competitors," he said.

Additionally, it is generally believed that these advances in technology will not affect the way in which ophthalmologists practice other than there may be more of a need to combine resources. "There will be a need for ophthalmologists to work together in group practices so there will be subspecialities in each office," confirmed Dr Mertens. Dr Grabner responded to this by stating that there will probably be more need for technicians to handle all the laser programming and upkeep of new devices.

The future of FACS

Both Dr Grabner and Prof. Alió agreed that technology in cataract surgery will continue to wow us next year with many papers due to be published including large series of patients the benefits will become clear. Dr Mertens' personal experience with the Victus formed part of his predictions for the future. "With this femtosecond laser you can treat presbyopia (Intracor), make flaps, corneal incisions and arcuate incisions. You can also perform corneal transplants and, of course, perfectly round capsulorhexis is possible for fragmentation of the lens nucleus," he said. "The effective lens position will be much more predictable with FACS and also the rhexis is stronger and better centred than manual rhexis."

"In fact," agreed Dr Franchini, "being able to perform surgery with laser anterior capsulotomy, corneal incision — which can be used as a cataract tunnel — paracentesis, relaxing incisions and so on is a great benefit. Also, an OCT guided nuclear fragmentation, will probably increase refractive results, reducing the risk of complications, such as posterior capsule rupture, endophthalmitis and endothelial cell density loss. The first clinical results show that the femtosecond laser has the potential to cut the nucleus to the desired size and shape."

As stated earlier, FACS is a new technology and many more questions still need to be answered before the full extent of its penetration into the industry will be completely understood. Dr Grabner believes that FACS will have the most impact next year also. "Many publications will be coming out very soon definitely showing the benefit for the patients and not solely for the industry," he said.

"I believe that it is easy to imagine FACS will penetrate the market in the future, allowing our patients to take full advantage of all the benefits of premium IOLs," added Dr Franchini.