Guest Editorial Philippine Journal of OPHTHALMOLOGY

Is Femtosecond Technology the Future of
our Cataract Surgery?
Richard C. Kho, M.D.
Department of Ophthalmology and Visual Sciences
Philippine General Hospital
University of the Philippines Manila
Email: rich_kho@yahoo.com

Introduction More of the same—nearing the theoretical
limits of phacoemulsification technology and
Techniques and technology for modern-day techniques
cataract surgery have taken quantum leaps over the
past several decades. We appreciate today’s technology Essentially, we still want more of the same things
and innovations since we know how it all started. and we want to make them even better, as we reach
If we look back at how our profession dealt with the summit of phacoemulsification technology and
cataract removal a century ago, fifty years ago, or even techniques. We want more and more IOL position
ten years ago, we will realize that the refinement of predictability in order to achieve our target refractions.
technology and surgical techniques in cataract surgery To do that, we want to create consistently reproducible
is one of the greatest success stories in the annals of capsulotomy size and shape.4 In addition, we still want
medicine.1 Cataract surgery today remains one of the consistently reliable corneal incisions and arcuate
most successful and commonly performed procedures incisions to control astigmatism.5 And finally, we still
worldwide.2 want to keep reducing surgical trauma inside the eye
during surgery, resulting in clear corneas immediately
From ECCE to Phacoemulsification and thereby maintaining the “wow factor” in our
patients.6
In the latter part of the last century, we
accomplished the full transition from extracapsular From a technical and engineering standpoint,
cataract extraction (ECCE) to small-incision surgery. we may already be reaching the limits of what
Over the years, we have refined our surgical techniques phacoemulsification machines using ultrasound power
to a point where we could remove the cataract through can do. Most of the newer generation phaco machines,
a very small, nearly astigmatically-neutral incision. in the hands of a capable surgeon can deliver excellent
But none of these surgical refinements would have surgical results with the least amount of ultrasound
been possible without a parallel rise in the technology damage to the corneal endothelium. But one can
surrounding them. From the first phacoemulsification only do so much tinkering with phacoemulsification
machine introduced by Dr. Charles Kelman in 1967, settings along the physical limits of ultrasound
we now have 4th and 5th generation phaco machines energy. And from a surgical viewpoint, we may also
that help us deliver excellent surgical results with the be reaching the limits of what human hands can do.
least amount of trauma to the eye.3 And of course, We have shown that we can do fairly round (but not
from the first rigid intraocular lens (IOL) implanted perfect) anterior capsulotomies, and fairly consistent
by Sir Harold Ridley in 1949, advanced-technology (but not always) corneal incisions. Where do we go
IOLs customized toward the patient’s needs have from here?
become available in our daily practice. What then, is
next in our never-ending quest for “perfect vision” And so the femto wars begin…
after cataract surgery?
Philipp J Ophthalmol 2013;38:1-4 The so-called “femto wars” actually began many

January - June 2013 

10-13 had yet to be refined. we all Are we now witnessing in cataract surgery the same know which technique came out on top. there are four companies offering we currently argue that our phacoemulsification is the femtosecond platform for cataract surgery: the “just as good as femto” and. etc. But as we phacoemulsification. historical path as phacoemulsification did? That is Chronologically. and the Alcon LenSx (ALCON ophthalmic equipment. we eventually found out that with the proper  Philippine Academy of Ophthalmology . and corneal incisions. And since our collective skills in consistently reproducible capsulotomy size and phacoemulsification surgery then were still raw and shape. more than 80% of LASIK flaps in the United It is interesting to note that many of the counter- States are created using the femtosecond laser. Inc. need to shift techniques? Déjà vu.. that branch of our profession eventually 1% of cataract surgeries done in the country today adopted femto-created flaps as the standard for are femtosecond-assisted. years ago. Today. it was not uncommon for many local practitioners to shy away from shifting to phacoemulsification Recent applications in cataract surgery have simply because they were confident enough in their demonstrated that the femtosecond laser can achieve ECCE results. see no urgent Lens AR Laser System (LensAR. 15 years later and nearly every ophthalmology low endothelial cell counts. Local ophthal­ which have penetrated the local market. femtosecond cataract explored for refractive surgery in order to create better surgery is virtually in the same status where corneal flaps without the use of a microkeratome. CA). NY). hypermature. Will it follow the same laser-assisted-in-situ keratomileusis (LASIK) surgery.) and would quickly graduate in the country now routinely perform find any reason to do ECCE instead. many ophthalmologists likely In short. Fort Worth. as cataracts” (brunescent. Clara. the demand would come and patients were willing and For many of our local faculty teaching able to shell out the extra expense for premium eye phacoemulsification surgery today. therefore. and a doubtful return-on-­ Laboratories Inc. as historical route taken by refractive surgery? we have come to realize that a well-performed phacoemulsification is far superior than ECCE.9 time. TX)—nearly all of investment (ROI) was a concern. i. began during the mid to late 90’s. which was soon replaced by microkeratome LASIK. intumescent it eventually did in the United States.14 Can Currently. phacoemulsification represented less than 1% of Finally. presence of zonulysis. the journey care. The culture phacoemulsification training at that time discouraged of ECCE was so ingrained in our residency training many local surgeons from immediately adopting and clinical practice that few people believed the technique. non-dilating pupils. and phacoemulsification of the last decade. In the ensuing “battle” between ECCE theoretical reduction in human error and variability. local history technology in our local practice told us that if superior technology was made available. the learning curve associated with cataract surgeries done in the country. phacoemulsification machines the Catalys Precision Laser System (OPTIMEDICA. mologists were also worried that patients might balk at the extra expenses incurred by choosing Historical perspectives on the adoption of new phacoemulsification over ECCE. radial keratotomy (RK) was soon currently the half-a-million dollar (cost of the femto followed by photorefractive keratectomy (PRK). At the and refractive surgeries. during the early days of phacoemulsification would one day supplant ECCE our phaco learning. lens fragmentation. less than And in time.7-8 phacoemulsification was 15 years ago. And in fact. as phacoemulsification machines collectively refined our surgical techniques over the have become ubiquitous in hospitals and ambulatory years.e. At the time.. Again. and arguments put forth by local ophthalmologists a refractive surgeons are finding more and more uses decade ago on the need to shift from ECCE to for the femtosecond laser in various types of cornea phacoemulsification are making a comeback. Orlando. we tried to avoid the “difficult as the gold standard for cataract surgery locally. machine) question. we are trying to “automate” many of the produced ECCE results that were “just as good human steps involved in cataract surgery with the as phaco” and did not see the urgent need to shift use of femtosecond technology and expect to see a techniques. Fast-forward cataracts. were considered expensive relative to all our other Sta. We know that this technology was first surgical eye centers. Rochester. the Victus Femtosecond Laser Platform (Technolas Perfect Vision/Bausch + Lomb. FL).. Also at the time. Today.

J Cataract Refract Surg 2007. This second wave will also involve practically any cataract case presented to us. It is here. et al. from one article back in European CE and US FDA for various applications 2005 to 57 articles as of June 2013.net/crstoday/pdfs/crst0304_f9_masket.pdf The second wave of “femto wars” will likely (accessed June 4. Microlab/ with more than a thousand surgeons combining for Zeiss. as well as lowering the cost of incorporating study.. March 2004:77-80: http:// bmctoday. 2013). the learning curve shortened especially for capabilities. truly is. A recent PubMed search on In the early years of the “femto wars”. That. benefited from the teachings of early adopters of “mobile” femtosecond cataract machines may be phacoemulsification in the country. He a total of over 100. i. over 7. as the “femto wars”drag further on ation. lens fragment­. 2. the ultimate beneficiaries will incisions. I say let the using the AlconLenSx. another References three or four femtosecond cataract platforms from 1. The future of By late 2011. Kelman CD. So is femtosecond technology the future of And as the sharing of techniques accelerates our cataract surgery in the Philippines? skills in femtosecond-assisted cataract surgery.June 2013  . & Refractive Surgery Today. In addition. Philippine Journal of OPHTHALMOLOGY techniques and instrumentation. currently the most commercially successful among the femtosecond platforms Currently. Closer to home. the main stumbling block to mass globally. And if we go by the undoable when this technology was first introduced history of phacoemulsification adoption in the for cataract surgery. In due enhancements that incorporate refractive and cataract course. it may be safe to assume that femtosecond- assisted cataract surgery will eventually follow a similar The next phase of the femto wars is underway route. albeit a slower one than our shift from ECCE to phacoemulsification.000 procedures (Alcon LenSx was also a co-investigator for various clinical trials with the Clinical Training Records). But make no of femtosecond technology in cataract surgery. one machine that can be used both the younger generation of phaco surgeons who have for cataract surgery and LASIK flaps.19 emulsification surgery. the other femtosecond platforms eventually be ophthalmologists and their patients as did not take long in reaching their own approvals competition and rivalry among various femtosecond and have since gained similar traction commercially. Cataract in the country as of press time. Erie JC. was the first femtosecond machine approved adoption is still the cost of purchasing and maintaining in the United States for all three applications in the machine.e. Hodge DO. However. as well as the added expenses to the cataract surgery. The Alcon LenSx. patient. then the transition to femtosecond-assisted surgery will likely be faster. the femtosecond assisted cataract surgery revealed few battle was essentially a race to get approval from the published literature so far. He has received travel assistance from Allergan. after the first commercially available femtosecond cataract machine was installed at a local eye center in October of 2011.1 cataract platforms bring the cost down. them in our clinical practice factoring in the cost 3. In a span of less than two years..17 country. The evolution of small-incision cataract surgery: different companies have been or are being installed a short history of ophthalmologists’ progress. Currently. interest in any of the machines mentioned in this article. we can indeed and maintenance of the machine and added cost perform good phacoemulsification surgery in to the patient.33:1273-1277.15-16 If one can do good phaco­ your own operating room. Masket S. i. exponential LenSx from 2011-2012. mistake. The genesis of phacoemulsification: a look back by January .000 cases had been performed our cataract surgery clearly looks bright.e. this number Editor’s Note: The author has no financial or proprietary quickly ballooned to 250 machines in 56 countries. Incidence of cataract involve more improvements in these first generation surgery from 1980 through 2004: 25-year population-based machines. and corneal incisions including arcuate in the next few years. and Alcon for talks given locally and abroad. with 180 surgeons from 20 “femto wars”carry on. However. Baratz KH. the offered by enterprising individuals or companies learning curve in shifting from phacoemulsification that can bring this technology to your doorsteps on- to femtosecond-assisted cataract surgery is probably demand. without having the need to purchase one for even shorter. different countries utilizing this machine in their daily practice. It is happening. capsulotomy. we are now using femtosecond technology for difficult or The future looks really exciting for cataract complicated cataract cases that were initially thought surgeons in the Philippines. growth.

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