Robin G. Abell

Toward zero effective phacoemulsification time using femtosecond laser pretreatment.

OBJECTIVE To compare effective phacoemulsification time after femtosecond laser pretreatment with conventional phacoemulsification and the associated effect on visual outcomes and endothelial cell loss. DESIGN Prospective, consecutive, single-surgeon case-control study. CONTROLS Controls underwent phacoemulsification cataract extraction plus insertion of an intraocular lens (IOL). Cases underwent pretreatment with the femtosecond laser followed by phacoemulsification cataract extraction and IOL insertion. METHODS Two hundred one eyes underwent cataract surgery between April 2012 and July 2012. Data collected included patient demographics, preoperative characteristics, femtosecond lens fragmentation method, effective phacoemulsification time (EPT), intraoperative complications, and postoperative outcomes. MAIN OUTCOME MEASURES Effective phacoemulsification time, intraoperative complications, corneal endothelial cell loss, as well as postoperative best-corrected visual acuity, intraocular pressure, and refractive outcomes. RESULTS Patient demographics were similar between groups. There was no difference between baseline cataract grades (2.59 ± 0.71 vs. 2.52 ± 0.72, not significant). One hundred percent of cases pretreated with the femtosecond laser had complete capsulotomy. Mean EPT was reduced by 83.6% in the femtosecond pretreatment group (P<0.0001) when compared with controls, with 30% having 0 EPT (P<0.0001). Effective phacoemulsification time was reduced 28.6% within the femtosecond group using improved lens fragmentation algorithms, and a further 72.8% reduction was achieved with a 20-gauge phacoemulsification tip. Overall, there was a 96.2% reduction in EPT between controls and the optimized femtosecond pretreatment group. This was associated with a 36.1% reduction in endothelial cell loss in the femtosecond group. Visual and refractive outcomes were similar to those of conventional cataract surgery. CONCLUSIONS Femtosecond laser pretreatment results in a significant reduction in effective phacoemulsification time, including the possibility of 0 EPT. Further reductions may be achieved using optimization of lens fragmentation patterns and surgical technique. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Femtosecond laser-assisted cataract surgery compared with conventional cataract surgery.

Background To investigate the safety and efficacy of the Catalys (Optimedica, Santa Clara, CA, USA) femtosecond laser-assisted cataract surgery system compared with conventional phacoemulsification cataract extraction. Design Prospective, consecutive, parallel cohort study. Participants The first 200 eyes undergoing conventional cataract surgery to the first 200 eyes undergoing femtosecond laser-assisted cataract surgery between April and July 2012. Methods Femtosecond laser-assisted cataract surgery involved anterior capsulotomy and lens fragmentation based on optical coherence tomography-guided treatment mapping. Conventional cataract surgery involved manual continuous curvilinear capsulorhexis. Both procedures were completed by standard phacoemulsification and insertion of an intraocular lens. Main Outcome Measures Effective phacoemulsification time and intraoperative complication rates. Results Patient demographics were similar between both groups. There was no statistically significant difference in intraoperative complications between femtosecond laser-assisted cataract surgery and conventional surgery. There was one posterior capsule rupture in both groups (0.5%; not significant). One hundred per cent of cases treated with the femtosecond laser had a complete capsulotomy. Vacuum time decreased with experience. Effective phacoemulsification time was reduced by 70% in the femtosecond group (P < 0.0001). Twenty-six cases in the femtosecond group versus one case in the conventional group had 0 effective phacoemulsification time (P < 0.0001). Conclusion Femtosecond laser-assisted cataract surgery appears to be as safe as conventional cataract surgery in the short term and results in significantly lower effective phacoemulsification time. Although it may allow for greater efficiency and decreased postoperative complications, further research is needed into long-term safety aspects such as corneal endothelial cell loss.To investigate the safety and efficacy of the Catalys (Optimedica, Santa Clara, CA, USA) femtosecond laser‐assisted cataract surgery system compared with conventional phacoemulsification cataract extraction.

Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: Outcomes and safety in more than 4000 cases at a single center

Purpose To compare the intraoperative complications and safety of femtosecond laser–assisted cataract surgery and conventional phacoemulsification cataract surgery. Setting Single center. Design Prospective consecutive comparative cohort case series. Methods Eyes had femtosecond laser–assisted cataract surgery (study group) or phacoemulsification (control group) by 1 of 5 surgeons. The technique comprised manual corneal incisions and capsulorhexis or laser–assisted anterior capsulotomy, lens fragmentation, corneal incisions, phacoemulsification, and intraocular lens implantation. Results The study group comprised 1852 eyes and the control group, 2228 eyes. Patient demographics were similar between groups. There was a significant improvement in vacuum/docking attempts, surface recognition adjustments, treatment, and vacuum time during the laser procedure in the study group. Anterior capsule tears occurred in 1.84% of eyes in the study group and 0.22% of eyes in the control group (P < .0001). There was no difference in the incidence of anterior capsule tears between the first half and second half of laser‐assisted cases. Anterior capsulotomy tags occurred in 1.62% study group eyes. There was no significant difference in posterior capsule tears between the 2 groups (0.43% versus 0.18%). The incidence of significant intraoperative corneal haze and miosis was higher and the effective phacoemulsification time significantly lower in the study group (P < .001). Conclusions Significant intraoperative complications likely to affect refractive outcomes and patient satisfaction were low overall. The 2 cataract surgery techniques appear to be equally safe. Although anterior capsule tears remain a concern, the safety of femtosecond‐assisted cataract surgery in terms of posterior capsule complications was equal to that of phacoemulsification. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Intravitreal injections: is there benefit for a theatre setting?

Objective To investigate and compare the rate of endophthalmitis after intravitreal injections performed in an in-office (dedicated procedure room) versus in-theatre setting. Methods A retrospective comparative cohort study was performed of all patients consecutively treated by a single surgeon with intravitreal injection with either ranibizimab or bevacizumab for any recognised clinical indication. All cases received injections between March 2006 and March 2012, during which time all injections were prospectively recorded on an electronic medical record system. A search of the electronic database using a report building system was used to extract the total number of injections into location-specific grouping (ie, in office vs in theatre). Results 12 249 injections were performed over a 6-year period. 3376 of these were performed in the in-office procedure room, compared with 8873 in the operating theatre. Of the 3376 injections performed in office, there were four cases of infective endophthalmitis compared with none of the 8873 injections performed in theatre (p=0.006). In-theatre intravitreal injections were associated with a 13-fold lower risk of endophthalmitis compared to in-office injections. Conclusions The theatre environment is a clinically appropriate location for any intravitreal injection procedures and was associated with a significantly lower risk of infective endophthalmitis in this single-surgeon comparative cohort study.

Cost-Effectiveness of Femtosecond Laser-Assisted Cataract Surgery versus Phacoemulsification Cataract Surgery

PURPOSE To perform a comparative cost-effectiveness analysis (CEA) of femtosecond laser-assisted cataract surgery (LCS) and conventional phacoemulsification cataract surgery (PCS) DESIGN: Retrospective CEA using computer-based econometric modeling. PARTICIPANTS Hypothetical cohort of patients undergoing cataract surgery in the better eye based on a review of the current literature and our direct experience using LCS. METHODS A cost-effectiveness decision tree model was constructed to analyze the cost-effectiveness of LCS compared with PCS. Complication rates of cataract surgery were obtained from a review of the current literature to complete the cohort of patients and outcomes. This data was incorporated with time trade-off utility values converted from visual acuity outcomes. MAIN OUTCOME MEASURES Improvements in best-corrected visual acuity obtained from the literature were used to calculate the increase in quality-adjusted life-years (QALYs) in a hypothetical cohort between 6 months and 1 year after cataract surgery. This was combined with approximate costs in a cost-utility analysis model to determine the incremental cost-effectiveness ratios (ICERs). RESULTS Based on the simulated complication rates of PCS and LCS and assuming resultant visual acuity outcome improvement of 5% in uncomplicated cases of LCS, the cost-effectiveness (dollars spent per QALY) gained from LCS was not cost-effective at

Effect of femtosecond laser–assisted cataract surgery on the corneal endothelium

92 862 Australian Dollars. The total QALY gain for LCS over PCS was 0.06 units. Multivariate sensitivity analyses revealed that LCS would need to significantly improve visual outcomes and complications rates over PCS, along with a reduction in cost to patient, to improve cost effectiveness. Modeling a best-case scenario of LCS with excellent visual outcomes (100%), a significant reduction in complications (0%) and a significantly reduced cost to patient (of

Anterior chamber flare after femtosecond laser–assisted cataract surgery

300) resulted in an ICER of

Intraocular pressure during femtosecond laser pretreatment of cataract

20 000. CONCLUSIONS Laser cataract surgery, irrespective of potential improvements in visual acuity outcomes and complication rates, is not cost effective at its current cost to patient when compared with cost-effectiveness benchmarks and other medical interventions, including PCS. A significant reduction in the cost to patient (via reduced consumable/click cost) would increase the likelihood of LCS being considered cost effective.

A Comparative Cohort Study of Visual Outcomes in Femtosecond Laser-Assisted versus Phacoemulsification Cataract Surgery

Purpose To compare the effect on the corneal endothelium of femtosecond laser–assisted cataract surgery and conventional phacoemulsification cataract surgery. Setting Private clinic, Tasmania, Australia. Design Prospective comparative cohort study. Methods Femtosecond laser–assisted cataract surgery (study group) or conventional phacoemulsification (control group) was performed. The central corneal thickness, central 3.0 mm corneal volume, volume stress index, and central endothelial cell density (ECD) were measured preoperatively and 1 day, 3 weeks, and 6 months postoperatively. Results The study group comprised 405 eyes and the control group, 215 eyes. Postoperative corneal edema was significantly less in the study group at 1 day and 3 weeks. However, the difference was negligible at 6 months. The study group had significant reductions in ECD loss compared with the control group at 3 weeks but not at 6 months (6‐month mean −150 cells/mm2 ± 244 [SD] versus −149 cells/mm2 ± 233). Eyes in the study group with laser‐automated corneal incisions had greater endothelial cell loss at 6 months than eyes in the study group with manual corneal incisions and eyes in the control group (P<.0001). Eyes in the study group with zero effective phaco time and manually created corneal incisions had statistically significantly less endothelial cell loss at 6 months than the other groups (P<.0001). Conclusions Femtosecond laser pretreatment for cataract surgery was associated with a significant reduction in early postoperative corneal edema and endothelial cell loss compared with conventional phacoemulsification; however, the difference diminished with time. Laser‐automated corneal incisions seemed to adversely affect the corneal endothelial cells. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.

Cystoid macular edema after femtosecond laser-assisted versus phacoemulsification cataract surgery.

Purpose To determine whether postoperative ocular inflammation is less after femtosecond laser–assisted cataract surgery than after conventional phacoemulsification (manual) cataract surgery. Setting Private clinic, Launceston, Tasmania, Australia. Design Prospective consecutive investigator‐masked nonrandomized parallel cohort study. Methods Consecutive cataract patients who had femtosecond laser–assisted cataract surgery or manual cataract surgery by the same surgeon at a single center were assessed. The primary endpoint was postoperative aqueous flare measured by laser flare photometry at 1 day and 4 weeks. Secondary endpoints included retinal thickness measured by optical coherence tomography and slitlamp examination findings at 4 weeks. Results The per‐protocol population comprised 176 patients (100 in laser group; 76 in manual group). Postoperative aqueous flare was significantly greater in the manual cataract surgery group at 1 day (P=.0089) and at 4 weeks (P=.003). There was a significant correlation between effective phacoemulsification time and 1‐day postoperative aqueous flare (r = 0.35, P<.0001). The increase in outer zone thickness measured by optical coherence tomography was less in the laser group (P=.007). Conclusion Anterior segment inflammation was less after femtosecond laser–assisted cataract surgery than after manual cataract surgery, and this appeared to be due to a reduction in phacoemulsification energy. Financial Disclosure No author has a financial or proprietary interest in any material or method mentioned.