Review of the Year: 2012

Cataract & Refractive 2012

Reviewed by Professor Jorge L. AliÓ, Professor Günther Grabner and Professor Alessandro Franchini

As predicted in last year's review femtosecond laser assisted cataract surgery (FACS) is still the front runner for cataract and refractive surgeons in terms of innovation and development. However, that still does not mean that other sectors of the industry weren't proving exciting as well. In this review of the year, we discuss what has been a highlight of 2012 with Professors Jorge L. AliÓ, Günther Grabner and Alessandro Franchini and we also examine what predictions they have for next year.

"Once again this year I would say the most important innovation has been FACS," said Prof. Grabner. Not only has it proven to be the biggest opportunity of the year in Prof. Grabner's opinion but he expects that it will also boost the cataract and refractive sector and will make a lot of waves in the industry.

"One of the most important innovations of the year is FACS," agreed Prof. AliÓ, "however, one of the main limitations is the huge financial contraint that the technique has for both doctors and patients. At present costs, the technique is going to have a lot of difficulties to be generalized because of the extra expense per procedure."

Prof. Franchini also agreed with the importance of FACS. "As it is well known, the use of a femtosecond laser can improve the quality of cataract surgery in two different phases," he added. "Firstly, it enables surgeons to perform a perfect capsulorhexis in terms of precision and reproducibility of desired diameter shape and centration, and it enables creation of very precise corneal tunnels and paracentesis, which can be fundamental for surgical success."

The second improvement that Prof. Franchini emphasized was gained through the use of FACS is phacofragmentation. "This allows us to optimize our ultrasonic phacoemulsifier parameters and our surgical techniques so that we use as little energy as possible in removing the fragments at all grades of nucleous densities," he said. "In my opinion, the first point is already a reality today. However, I believe we are at the beginning of the improvement of laser phacofragmentation and its ability to completely remove all types of nuclei without ultrasound safely and quickly."

Currently, there is still some controversy over the potential of phacofragmentation increasing the risk of posterior capsule rupture and difficulties in cortex removal, which have been raised as issues in several papers.^1–5 "So, I think that there is still progress to be made before we will be able to perform nucleous aspiration, in all cataract grades, with a laser alone and without the help of ultrasound," asserted Prof. Franchini. "Furthermore, after the correction of refractive diseases and cataract surgery in the near future there will be other interesting ophthalmic applications for FACS, such as the correction of presbyopia, corneal collagen crosslinking, treatment of tractional vitreous attachments and also the possibility of using this technology in glaucoma surgery to perform goniotomy and trabeculectomy."

Presbyopia solved already?

"Presbyopia correction has gone through multifocal emerging intraocular lenses (trifocal especially) and also intracorneal inlays," said Prof. AliÓ. "Of these inlays, both the KAMRA (AcuFocus, Irvine, California, USA) and the Flexivue (Presbia, Irvine, California, USA) are providing a new way to treat patients with the advantage that, particularly with the KAMRA, the patients can be corrected by excimer laser at the same time as implantation. This guides the refractive outcome to a much more appropriate level. Also, the concept of reversibility offered by these implants is extremely appreciated by middle partial presbyopes adding an extra advantage."

In Prof. Grabner's opinion the problem of presbyopia can generally be considered as solved. "This problem has basically been solved by the introduction and commercialization of the KAMRA corneal inlay, which has now reached over 17000 implants worldwide," he said.

For Prof. Franchini, however, multifocal IOLs are still key for his presbyopic patients. "In fact, with a good mix of lens quality, ability in the selection of the patient and surgical perfection (a circular and well centred capsulorhexis of the right dimension, a meticulous attention in posterior capsule cleaning, an astigmatically neutral surgery etc.) the mutlifocal IOLs still represent the best option today to correct presbyopia, providing our patients with good vision at all distances," he added.

An exciting year for IOLs

For Prof. Franchini this year has been a very important one in terms of the improvement of refractive results in his cataract patients. "Having a large deposit of premium IOLs at the state university where I work allows me to implant a large number of lenses," he said. "I think that when speaking of toric IOLs, however, we should no longer count them as a 'premium IOL' as the results, in terms of visual acuity, contrast sensitivity, incidence of halos and glare, confirm that implantation of these lenses is a necessity in patients with significant corneal astigmatism, who account for around 30% of cataract patients."

Prof. Grabner agreed, stating, "Yes, toric multifocal IOLs are really well accepted by patients. Over the course of the next year I believe we will see many more toric multifocal IOLs being offered."

"This is particularly true for toric multifocal IOLs," confirmed Prof. Franchini. "These implantation procedures are required to achieve similar refractive outcomes to emmetropia. It is estimated that in times of economic crises the toric IOL market will increase more than 50% next year compared with this year."

However, over the past decade there has been patient dissatisfaction regarding multifocal IOLs. Prof. Franchini remarked that if there is any small imperfection in the optical system the performance of a multifocal IOL can deteriorate. "So, I think that multifocal IOLs that have been designed paying more attention to PCO prevention, reducing high levels of spherical and chromatic aberrations avoiding glistenings and in general all the cylindrical refractive errors, will ensure patient satisfaction," he said.

In Prof. AliÓ's opinion it has been an extremely exciting year for IOLs and he believes that one of the most important innovations has been the trifocal lens. "The Mplus (Oculentis, Berlin, Germany) +3 and +1.5 D has become standard in my practice due to the capability of these lenses in the +3 model to provide continuous vision at all distances," he said. "During the year, the new trifocal lenses, Finevision (PhysIOL, LiÈge, Belgium) and AT LISA tri (Carl Zeiss Meditec, Jena, Germany), have become part of my practice as well, creating a much better profile for my patients."

Further to this Prof. AliÓ remarked that the ReSTOR +3 and +2.5 (Alcon Laboratories, Fort Worth, Texas, USA) have also moved forwards when compared with the previous model, offering better intermediate vision and creating a continuous vision from near and intermediate distances. "In summary," he added, "the year has been very productive in terms of multifocality and less in terms of accommodative IOLs, which have basically failed."

What the future holds

The future of IOLs and the diffusion of toric lenses into more standard practices was agreed upon by all of our contributors. "I don't imagine great innovation next year as far as the types of IOL are concerned, but I am sure that we will experience an increase in premium IOL diffusion, in particular toric IOL diffusion," said Prof. Franchini. "In fact considering that 30% of cataract patients can gain great advantages from implantation of a toric lens it is unacceptable that today only a small proportion of these patients receive this implant. This is not justifiable adducing only economic reasons considering the enormous amount of money that will be spent on toric spectacles for the rest of the patient's life. Perhaps the introduction in the public health sector of the highly debated co-payment could be a valid compromise."

Prof. AliÓ believes that toric IOLs will become the standard of practice and that most multifocal IOL models will offer toricity correction as an alternative. "Also, I believe the concept of continuous vision will be more and more developed in multifocal IOLs," he continued. "And I am sure that accommodative IOLS will have a revival but it will be with completely different models to those we were using in the past."

For all of our expert contributors, FACS will continue to be important in the future. "FACS will continue to be impactful next year, with improvements in safety and surgical precision after a short learning period for surgeons taking up the procedure," said Prof. Grabner.

"I think after the first experiences gained in 2010, 2011 and 2012, next year will represent the year in which FACS will start to be used by an even larger proportion of surgeons, reaching the final acceptance of this technology and enabling the development of new applications and indications," asserted Prof. Franchini. "I am very excited about this innovative and fascinating technology for its potental to enhance refractive outcomes in my patients. I don't know if the femtolaser will represent the future in cataract surgery but when you consider we are only at the first generation of this technology, the future appears promising."

Although in agreement with the others about FACS, Prof. AliÓ also heeded a word of warning regarding the procedure. "Even though, at meetings, FACS will be a big hit in the coming 2 years, the financial implications it has on surgeons and patients will most probably cause a slow acceptance of this procedure in practical terms," he concluded.

References

1. Z.Z. Nagy et al., J. Cataract Refract. Surg., 2012;38:941–946.

2. R.F. Steinert, Ophthalmology, 2012;119(5):889–890.

3. S.J. Bali et al., Ophthalmology, 2012;119(5):891–899.

4. Z. Nagy, J. Refract. Surg., 2009;25:1053–1060.

5. L. He et al., Curr. Opin. Ophthalmol., 2010;22:43–52.