12/3/2016 Saras Ramanathan, MD Associate Professor Division Chief, Comprehensive Ophthalmology � none UCSF 1985 1994 � How many of you are cataract surgeons? � How many are currently performing Femtosecond Laser Assisted Cataract Surgery (FLACS)? � How many think it has a useful place in your practice? Leaming, DL. Practice styles and preferences of ASCRSmembers-1994 survey JCRS 1995 21:378-385 1
12/3/2016 � Wound � Astigmatism Management � Capsulotomy � Lens “softening” � Intraoperative Complications � Lens Position/Centration � Improved post-op Va � Metanalysis 68,000 eyes from ECCE, ICCE, Phaco � Cost Effective? � No difference in Va � Learning Curve � Patient Satisfaction � No difference in complications Arch Ophthalmol. 1994;112:239-252) FEMTOSECOND CATARACT SURGERY PHACOEMULSIFICATION � FLACS � MCS � LCS � PCS � Capsulotomy � Capsulorhexis � AK � LRI / PCRI Conclusions: There were no statistically significant differences detected between FLACS and MCS in termsof patient-important visual and refractive outcomes and overall complications. Although FLACS did show a statistically significant difference for several secondary surgical outcomes, it was associated with higher prostaglandin concentrations and higher rates of posterior capsular tears. 2
12/3/2016 � Wound � Post-operative course � Reproducibility � PCO � Induced astigmatism � Capsule contraction � Self-sealing � Lens tilt, aberrations � Astigmatic treatment � Learning Curve � Predictability, Precision � Complication rate � Capsulotomy � Surgical time � Cost Effectiveness � Centration, Circularity, Completeness � Surgeon � Lens treatment � Patient • Self-sealing, reproducible wound with little induced astigmatism. � decrease US time and power � Patient Satisfaction • Astigmatism correction should be predictable and precise � Decreased post operative � Primary and secondary incisions � Effective treatment of low level astigmatism central K thickness with FLACS show no difference in: � Studies mostly from refractive surgery literature � Slightly less endothelial cell loss � Surgically Induced Astigmatism with FLACS � Equivalent to toric IOL � Higher order aberrations from � Fewer Descemet detachments wound � Await nomograms specificially for laser AK / FLACS with FLACS � Wound sealability Day, et al. Correction of astigmatism at the time of cataract surgery. Curr OpinOphthalmol, 20 (2009), pp. 19–24 Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “ Efficacy and Safety of Femtosecond Laser- Hayashi K et al. Effect of astigmatism on visual acuity in eyes with a diffractive multifocal intraocular lens. J Cataract Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005 Refract Surg. 2010 Aug;36(8):1323-9. doi: 10.1016/j.jcrs.2010.02.016. Nagy, Z et al. Evaluation of femtosecond laser-assisted and manual clear corneal incisions and their effect on surgically induced Yoo A. Femtosecond Laser-assisted Arcuate Keratotomy Versus Toric IOL Implantation for Correcting Astigmatism . J astigmatism and higher-order aberrations . J. Refract Surg 30:8 522-525 Aug 2014. 10.3928/1081597X-20140711-04 Refract Surg. 2015 Sep;31(9):574-8. doi: 10.3928/1081597X-20150820-01. 3
12/3/2016 � Decreased phaco time � Increased posterior capsule � Decreased phaco energy rupture � Slightly protective to � Increased anterior capsule tags endothelium and tears � Decreased post op central � Increased prostaglandin release corneal thickness � Unchanged or slightly increased case time Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005. Effect on US time and power with secondary effect on cornea Abell RG et al. Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single center. J Cataract Refract Surg. 2015 Other Intraoperative factors Jan;41(1):47-52. doi: 10.1016/j.jcrs.2014.06.025. Epub 2014 Nov 11. � Capsulotomy slightly more circular, centered � Strength comparable to manual capsulorhexis � Better IOL overlap � Slightly less PCO Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005 Centration, Circularity, Completeness Kovács I, Nagy ZZ et al. The effect of femtosecond laser capsulotomy on the development of posterior capsule opacification. J Refract Surg. 2014 Mar;30(3):154-8. doi: 10.3928/1081597X-20140217-01. Implications for capsule contraction and PCO Grewal DS et al. Femtosecond laser-assisted cataract surgery--current status and future directions. Surv Ophthalmol. 2016 Mar-Apr;61(2):103-31. doi: 10.1016/j.survophthal.2015.09.002. Epub 2015 Sep 26. 4
12/3/2016 � Less lens tilt � No diffce in UCVa with premium � No difference post-op visual acuity regardless of IOL type � Decreased AC depth variability IOLs � Toric, multifocal, monofocal � Some studies suggest � Toric, multifocal have equal UCVa � Corrected, uncorrected Va no different from phaco alone decreased internal aberrations, with FLACS vs. Phaco others show no difference Popovic, Marko, Xavier Campos-Möller, Matthew B. Schlenker, and Iqbal Ike K. Ahmed. “Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery.” Ophthalmology 123, no. Toto, L. et al. Postoperative IOL Axial Movements and Refractive Changes After Femtosecond Laser-assisted Cataract 10 (October 2016): 2113–26. doi:10.1016/j.ophtha.2016.07.005 Surgery Versus Conventional Phacoemulsification. J Refract Surg. 2015; 31(8):524-530. doi:10.3928/1081597X- 20150727-02 Ewe SY, et al. A Comparative Cohort Study of Visual Outcomes in Femtosecond Laser-Assisted versus Phacoemulsification Cataract Surgery. Ophthalmology. 2016 Jan;123(1):178-82. doi: 10.1016/j.ophtha.2015.09.026. Lawless M. Outcomes of femtosecond laser cataract surgery with a diffractive multifocal intraocular lens. Epub 2015 Oct 31. J Refract Surg. 2012 Dec;28(12):859-64. doi: 10.3928/1081597X-20121115-02. � Under the least advantageous scenario our surgeon has decided to purchase the OWN LASER SHARED LASER laser himself or herself, convinces 30% of his or her patients to pay for the laser, and experiences a 30% decline in productivity because of the laser. This results in # FLACSCASES 105 105 (1000 cases total) 105 cases generating an additional US $102 375 of revenue, but with additional PER YEAR costs of US $164 010, a net loss of US $61 635. Clearly, this is not a sustainable REVENUE $102,375 $102,375 situation and suggests that lone practitioners may not find FLACS a viable procedure. Certainly, the situation improves if our surgeon uses a shared laser COSTOF LASER $164,010 $54,810 with a total volume of 1000 cases per year. The total cost for 105 cases falls to US $54 810, netting the surgeon US $47 565. We think this is probably the most like ANNUAL PROFIT ($61,635) $47,565 general scenario, larger groups of average volume surgeons banding together to OR (LOSS) purchase a laser. Bartlett JD1, Miller KM. The economics of femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol. Bartlett JD1, Miller KM. The economics of femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol. 2016 Jan;27(1):76- 2016 Jan;27(1):76-81. doi: 10.1097/ICU.0000000000000219. 81. doi: 10.1097/ICU.0000000000000219. 5
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