STAR WARS and FEMTO-LASER CATARACT SURGERY

STAR WARS and FEMTO-LASER CATARACT SURGERY

Perhaps this holiday season you’ll see the latest chapter in the Star Wars saga.  If you are like me you’ll be impressed by the strong role played by technology in the film (or perhaps the triumph of the mental over technology).  Ophthalmology is a field powerfully influenced by technology.  For many yes lasers have been in common use for clearing lens opacities and for treating glaucoma and diabetic retinopathy.   Femto laser is the new technology on the block.  Femto Assisted Laser Cataract Surgery (FLACS) is a technology which has arisen from LASIK.  The machine is able to emit lights of wavelengths ten raised to the power of minus 15 meters.  The physicist in you may recall that short wavelength is coupled with high energy.   Amazingly the mechanism is able to identify anatomical structures and then perform a number of feats that are necessary for the beginning steps of cataract surgery.  The laser can make arcuate incisions in the cornea to lessen astigmatism, create an entry site for cataract surgical instruments, make an opening in the anterior lens capsule and begin to break up the cataract into pieces.  The scientific accomplishment is profound.  The practical accomplishment is less profound (to date).

Despite the incredible abilities of the laser, it still only performs a small portion of the cataract surgical procedure.  Phacoemulsification must still be performed after the FLACS procedure.  For example, an experienced cataract surgeon will typically perform a full surgery in 10-15 minutes.  The FLACS accomplishes steps that are typically completed without laser in 1-2 minutes.  However, the FLACS procedure requires 6-10 minutes after patient positioning in a separate room.  There are some concerns.  FLACS can leave tags in the capsule that can lead to complication if not recognized.  In response many surgeons use a short- lived stain on capsules routinely to detect this possibility.  FLACS is more likely to leave behind small pieces of the cataract in the eye, may cause mild intraoperative pupillary constriction, and may cause more inflammation in the early recovery period.  Rarely, the mechanism may misinterpret the anatomy of the eye.  If this occurs an attentive surgeon can redirect the laser.  FLACS, of course, has considerable expense that is not covered by insurances.

In some scenarios FLACS has definite advantages.  If a patient has weak zonules or a decentered lens prior to surgery, FLACS can reduce the total turbulence needed by the Phacoemulsification unit.  Patients with decompensating corneas will benefit from a reduction in the required Phacoemulsification power.  Some surgeons who are uncomfortable with the intraoperative treatment of astigmatism can instead utilize this technology.

The annual scientific meeting of The Academy of Ophthalmology dedicated a full session entitled “Laser- Assisted Cataract Surgery: Balancing Incremental Clinical Advantages with Learning Curves.”  The word “Incremental”  is used to indicate only a small practical advantage.  Among the questions addressed was the issue of whether FLACS was performed because surgeons truly believed there was a surgical advantage or whether surgeons were simply using FLACS because it was technology.

So should someone needing cataract surgery pay for FLACS?  Maybe, or maybe not.