Femtosecond Technology on the Western Slope

One of the most exciting aspects of eye care is the rapid development of technology, which then allows us to provide safer care and more predictable outcomes for our patient’s. I wanted to share new technologies available to our patients on the Western Slope.
Mr. Heckman also co-founded the Colorado Impact Fund, a Denver-based private equity fund that provides growth capital to emerging Colorado companies and entrepreneurs, and is the executive director of Quarterly Forum, a Denver-based leadership organization.

Over the last few decades there have been many technological breakthroughs that have made cataract surgery one of the safest surgeries that patient’s can go through. From the invention of phaco, to curvilinear capsulorhexis techniques, to the use of viscoelastics, to reducing the size of our incisions, eye care professionals have always been looking for ways to lower the risks associated with cataract surgery. At the same time as cataract surgery has became more reproducible and safe, attention has also been directed toward the refractive side of cataract surgery. Expectations of patient’s used to be that they would NEED to wear glasses, and now for most patient’s, a variety of options can be utilized to increase their spectacle independence.

Femtosecond laser assisted cataract surgery (FLACS) is the latest technology that combines improvements in safety and reproducibility, allowing us to be more confident then ever regarding patient outcomes. There are a variety of femtosecond laser platforms that are available, each with it’s own strengths and weaknesses. Currently there is only one femtosecond laser permanently in place here in the Western Slope: the Catalys by AMO (Abbott Medical Optics). I have had the privilege of being able to now use this on a regular basis, and there are a few takeaways I would like to share. I’m going to list them from the most highly contested to the least highly contested.

Femtosecond laser has the possibility of improving patient safety and reduce complications. For the average cataract patient, this has not been demonstrated in studies. The vast majority of studies looking at FLACS versus standard cataract surgery show no statistical difference in complication rates comparing the two groups (though recent meta-analysis of studies shows that there is an overall reduction in total phaco energy used in FLACS cases comparatively). The biggest takeaway one can glean from this is that cataract surgery is a very safe procedure regardless of approach for the vast majority of patient’s. Comparative safety of dense cataracts performed with both approaches has not been studied to a large enough degree to come to any conclusions through data alone. That said, very few surgeon’s who have access to both approaches believe that standard cataract surgery is safer for more complex cases (it should be noted that complex cases should be taken into consideration on a case by case basis and there is no “one size fits all” approach that should be ascribed to complex cases as a whole). Personally, I have found that higher density lenses that have been pretreated with the femtosecond laser creating the capsulorhexis along with the lens segmentation/fragmentation have lower time spent within the eye, lower phaco energy used, and less corneal edema compared to similarly complex cases performed solely with the standard technique. Though this is promising, it should be noted that for the most part this benefit is anecdotal at this time.

Femtosecond laser has the possibility of improving the reproducibility of our refractive outcomes from a spherical perspective. This statement is where there is likely the most contention in the literature, as some studies show a statistically significant advantage to FLACS, and others show no difference. Theoretically, when one maintains a consistent capsulorhexis size that is consistently reproducible at all times, this should create a reproducible effective lens position (ELP). Initially when FLACS came out, this was proposed to be a large benefit of FLACS, however, with time the data has been mixed. No studies since 2012 (to my knowledge) have shown an improvement in spherical refractive outcomes with standard cataract surgery, and several have shown an advantage in spherical refractive outcomes with FLACS. The fact that FLACS hasn’t shown to be overwhelmingly beneficial in the realm of spherical refractive outcomes likely lies in the fact that the capsulorhexis is only one aspect controlling ELP, with other independent variables playing into the final resting place of the intraocular lens along the axial plane.

Femtosecond laser has improved the reproducibility of our refractive outcomes from a cylinder perspective. Prior to FLACS, surgeon’s would use a fixed depth blade to perform LRI’s (examples included 600 micron and 500 micron fixed depth blades), with many surgeon’s finding an increasingly lower reliability as a patient’s astigmatism was above 1D of cyl. If every patient had identical corneal thicknesses at the location of these LRI’s, manual LRI’s would have a higher level of reproducibility and would be able to be used for higher diopteric levels of astigmatism. As we are all aware, patient’s do not have identical corneal thicknesses and the reproducibility of an LRI is greatly dependent on the % depth of the cornea that is treated. I have now used FLACS for ~2 years and the ability for the laser to reproducibly create astigmatic correcting incisions at a depth dependent on each patient’s individual corneal thickness is an incredible advance. The Catalys femtosecond platform creates astigmatically correcting incisions that are 80% of each individual cornea. If a patient has a 600 micron thick cornea at the area of treatment, the incision would be ~480 micron depth, etc with a precise 80% depth regardless of any individual’s corneal thickness. This degree of precision allows for an increase in reproducibility, as well as an increase in the amount of astigmatism one can expect to reproducibly be able to treat with an astigmatic correcting incision. This increase in reproducibility has led to an increase in reproducibility of cylinder correction via astigmatism correcting incisions, as well as increasing the number of patient’s that are good candidates for multifocal intraocular lenses (i.e. now patient’s with higher amounts of astigmatism can be reliable candidates).

Overall, technological improvements within ophthalmic surgery have led to improvements in the outcomes of our patients. Femtosecond laser assisted cataract surgery is yet another advancement available to us to improve our outcomes further and it is exciting that we can offer an increased level of precision and reproducibility to our patients.

About ICON Eyecare

ICON Eyecare is a leading surgical and medical eye care provider based out of Denver, CO. Since 1999, ICON has been building a Center of Ophthalmology Excellence empowered by an expert team of board certified physician specialists, the most advanced laser technology and a culture of quality and extraordinary patient care. In coordination with referring optometrists and physicians, ICON Eyecare specializes in treating patients with cataracts, advanced forms of glaucoma and other age and disease related conditions, while providing innovative options for patients seeking LASIK and cosmetic eye procedures. With 14 patient care centers located in Colorado and Texas, ICON Eyecare is expanding within the broader western U.S. region. For more information, please call (720) 524-1001, or visit iconeyecare.com.