Femtosecond lasers, safe, predictable and increasing in popularity but where will the industry go from here?
Femtosecond vs microkeratome: the battle continues
When considering refractive surgery advances, one contender for the top spot of technological innovations has to be the femtosecond laser. Love it or hate it, the femtosecond laser has revolutionized the field of refractive surgery since its introduction onto the US market in 2001 and three years later in Europe.
No one can deny that the femtosecond laser is safe, predictable and able to create neat and thin flaps. As a result the number of proponents of the technology has grown and consequently, the number of LASIK patients opting for femtosecond LASIK has increased dramatically.
According to Professor Dick, femtosecond laser technology marked a tremendous step forward in the evolution of refractive surgery. "We are very satisfied with our femtosecond laser both for PK surgeries as well as lenticular surgeries. The results are superb in terms of the accuracy of flap creation, the positioning, thickness and predictability," he said. Professor Dick is particularly impressed by the laser's ability to allow the surgeon to individually adjust flap thickness precisely depending on the needs of the eye and the treatment modality. "The patients definitely profit from it," he added.
His opinion was echoed by Professor Kuchynka who believes that the consistent and predictable flap thickness of the femtosecond laser can improve patient outcomes. "There is also less danger of microkeratome-related complications," he commented.
While there are many fans of the femtosecond, there are others that still remain cynical and believe that the microkeratome, particularly the newer generation of mechanical instrument, can achieve equally good results and costs a fraction of the price of a femtosecond laser.
Dr Vergés introduced the femtosecond laser for LASIK and corneal transplantation procedures into his practice this year. "I still successfully treat 90% of my patients with a microkeratome although I'm sure that femtosecond laser cuts are better. In my opinion, it's still early days with this technology and I do feel there is room for improvement," he said.
Indeed six years following the release of the first femtosecond laser, IntraLase is now onto its fourth-generation model. Meanwhile, Zeiss is chasing hot on its heels with the VisuMax femtosecond, which it hopes to release by the end of the year. According to Zeiss, as well as achieving excellent results, VisuMax provides the basis for a completely new surgical method for correcting visual defects, the so-called FLEx method (Femtosecond Lenticule Extraction). 20/10 Perfect Vision is also hoping for a slice of the action with the recent release of its new generation FEMTEC femtosecond pulse laser technology.
One thing that is certain, it seems that the femtosecond laser could have a large number of applications that extend far beyond it original intended use: to create LASIK flaps.
"We are very satisfied with our
femtosecond laser both for PK
surgeries as well as lenticular
surgeries…The patients definitely
profit from it"
For example, a role for the femtosecond laser is being investigated for a number of corneal procedures, including corneal transplantation. The hope is that investigators will find the optimum incision pattern that eventually leads to fewer sutures being required, or maybe even a combination of sutures and tissue glue.
Whether the femtosecond laser is embraced by the majority of the ophthalmic community remains to be seen, but it certainly seems that it's here to stay.
Femtosecond laser a feasible treatment option for presbyopia?
Another potential application for the femtosecond laser that has come to light is the treatment of presbyopia. Brought to life by a team including Professor Dick and supported by a €9.3 million grant from the German Health Ministry, a project is underway, which is examining femtosecond laser treatment of the natural lens.
"I currently do not treat presbyopia exclusively, either with conductive keratoplasty (CK) or LASIK, for example. I still don't believe we have the right tools available to us," admitted Professor Dick. Based on his knowledge of accommodation and the femtosecond laser, Professor Dick has set out to solve this problem.
The rationale behind this treatment comes from the knowledge of the sclerotic changes experienced by the lens with age and the exact location of these changes in elasticity. "We have been experimenting on porcine eyes, by applying different treatment patterns and modalities to see the influence on accommodation," said Professor Dick. The treatment is based on applying precise femtosecond cuts to the lens and, according to Professor Dick, several studies have thus far demonstrated no induction of cataract with this approach.
Industry and a team of researchers, which includes Professor Dick, has been working to build the laser, treatment chair and lens tracker. "This is totally brand new technology," he enthused.
"We have a 50:50 chance of success. If this treatment approach presents a viable option for presbyopia, without inducing cataract, that would be great," he added. The research team hopes to begin treating humans in two years.
…and still the patients want more
In light of surgical and technological advancements as well as the increasing knowledge of patients and their relatives, patient expectations have been undoubtedly growing over recent years. "I have seen a rise in the number of presbyopic cataract patients that do not want a standard monofocal, rather they are requiring a presbyopic-correcting IOL," confirmed Dr Kuchynka. Surgeons are therefore urged to be clearer and more straightforward in explaining the tentative outcomes of surgery to their patients, particularly those who suffer from other conditions, such as macular degeneration or advanced glaucoma. "Just a small misunderstanding between patient and surgeon could have legal implications. We must protect ourselves by providing adequate patient education and chair time," urged Dr Alió.
"Patients are looking for something
safe and efficient and industry
promises good news… Encouraging
progress has been made in the area
of presbyopia treatment but we
have yet to see something great"
Taking the example of presbyopia, Dr Vergés confirmed that patients expect more of surgeons when it comes to presbyopic correction, "Patients are looking for something safe and efficient and industry promises good news, but this has yet to arrive. Encouraging progress has been made in the area of presbyopia treatment but we have yet to see something great," he said.