Femtosecond lasers are making inroads in refractive surgery, so maybe it was only logical to expect them to make a run at cataract surgery, as well. Their advance started in earnest this spring at the annual meeting of the American Society of Cataract and Refractive Surgery, when researchers for Aliso Viejo, Calif., company LenSx Lasers presented initial data on the use of its femtosecond laser, the LenSx, in cataract surgery.
Then, in September, the company's laser received U.S. Food and Drug Administration 510(k) approval for creation of the capsulorhexis during cataract surgery. Here's a look at how the femtosecond cataract procedure works with the LenSx, and where the device may fit in the cataract surgery marketplace.

Houston surgeon Stephen Slade serves as medical director for LenSx Lasers, and has performed cataract surgery with the device. "It fixates the eye with a suction ring in a procedure that's similar to the IntraLase," he says. "Then, basically, you can use it to make the corneal incision, any astigmatic incisions such as limbal relaxing incisions, the capsulorhexis and the breaking up of the nucleus." The laser's parameters, such as the power settings and the depth of the ablation, are customizable.

The company is billing the LenSx as faster, more reproducible and more precise than manual completion of the various steps of cataract surgery. "And, hopefully, safer, as well," adds Dr. Slade. "I think you'd use less phaco with this technology. Hopefully, it will allow us to make an entrance wound that's very reproducible, as well as precise capsulotomies."

In a study of capsulorhexis creation commissioned by the company at Semmelweis University in Budapest, Hungary, and conducted by Zoltan Nagy, MD, the laser created capsulorhexes of the intended diameter 100 percent of the time. When a manual technique was used, the surgeon could get within ±0.25 mm in only 10 percent of cases.

Interestingly, the laser has also been used to break up the cataract itself. The emulsified material is then aspirated out of the eye using an irrigation/aspiration handpiece. For very hard lenses, it's possible that some phacoemulsification may be necessary. Dr. Slade says he "expects the laser to get better with time" in terms of its ability to chop.

Though the technology may be sound, the question remains whether surgeons, who are already successful with their current phaco equipment and cataract instruments, would take on the added expense of a new piece of equipment and its attendant learning curve.

"Hopefully, the precision, speed and possible increased safety will appeal to the surgeon and the patient," says Dr. Slade. "It has the potential to make patients more confident when deciding whether to undergo premium lens implantation."

As to how the cost of the laser will be presented to surgeons, a per-usage fee is probably in the cards. "I'm sure it will be some sort of combination of buying the device and paying per use," says Dr. Slade. "However, with the lasers we use in refractive surgery, I think we're kind of used to that approach now."