Femto Mania Continues: More Choices
Roger F. Steinert, MD: Hello. I am Dr. Roger Steinert, Director of the Gavin Herbert Eye Institute at the University of California, Irvine. By Skype™, I have with me 2 distinguished panelists -- Dr. Steve Lane and Dr. Tom Samuelson -- and we are going to be speaking about some of the highlights of the just-concluded annual meeting of the American Society of Cataract and Refractive Surgery (ASCRS).
Steve, tell us a little bit about yourself.
Stephen S. Lane, MD: My name is Stephen Lane. I'm from St. Paul, Minnesota, where I practice cornea and external disease, as well as refractive surgery and cataract surgery.
Dr. Steinert: Welcome, Steve. And Tom?
Thomas W. Samuelson, MD: My name is Tom Samuelson. I am a glaucoma anterior-segment surgeon in Minneapolis, right across the river from Steve. I have a practice at Minnesota Eye Consultants, and I also teach residents through the University of Minnesota. I am on the clinical faculty at Hennepin County Medical Center.
Dr. Steinert: Thank you both for taking the time to join Medscape.
ASCRS was filled with lots of exciting and new areas. One of the biggest topics still out there is femtosecond ("femto") laser cataract surgery. Steve, what is going on here? Is this still growing? Is it guaranteed to be taking over? Have you heard anything negative?
Dr. Lane: It is a very controversial subject, but certainly the interest continues to grow almost exponentially. Several different laser platforms are now available, and that is probably the most new and exciting development. Physicians in the United States now have a choice of 4 different lasers.
We are starting to see some results. The applicability and adjustability of many of the features are continuing to increase. The technology continues to evolve in a very short period of time. We are seeing an increased number of procedures, and an increased amount of interest.
There is still healthy skepticism and a lot of active debate. Cost probably remains the most significant barrier to the uptick of this technology, but we are starting to see how we can get better results in complicated cases, for example.
It remains a very exciting field. It will be the future (as everybody predicts), but we need to get a better handle on the financial aspects of it under most circumstances for it to continue to gain even more widespread applicability.
Dr. Steinert: Complications are not nonexistent with femto; they seem to be running at about the same level as conventional surgery, even for very skilled surgeons using conventional ultrasound. So, we are moving past that. We have been seeing many more presentations on the technical issues and refinements.
On the exhibit floor, the activity at the booths of the 4 current manufacturers was very high, and it sounds like Ziemer is about to enter the market as well, so pretty soon we may have a fifth platform.
Dr. Lane: I certainly agree with that. We are starting to see this becoming a much more portable type of technology. Buying it and having it stand in your ambulatory surgical center alone is evolving as well. Several companies are making their lasers mobile so that they travel around, and we are seeing that as an increasingly useful modality for people to get experience with it and make a decision about whether they want to purchase the device or use it in a mobile fashion coming off of a van. That seems to be working very well for many ophthalmologists.
Dr. Steinert: That makes it more of a game-changer, because it will make it more affordable as well as more accessible.
A Home Run for Microinvasive Glaucoma Surgery
Dr. Steinert: Equal to the femto mania is the microinvasive glaucoma surgery (MIGS) mania. The whole meeting was filled with the buzz over the innovations in glaucoma surgery. Tom, what's your take on all of this?
Dr. Samuelson: In many respects, it was a home run meeting for glaucoma in general and MIGS in particular. It was a home run in general because Rick Lewis, one of our glaucoma brethren, was honored with the presidency of ASCRS. Then, in the surgical section on glaucoma day, we had nearly 1000 people in the room -- which for glaucoma at an ASCRS meeting is pretty impressive. Of course, nothing is more mainstream at ASCRS than the Binkhorst Lecture, and Ike Ahmed[1] gave a fantastic talk on MIGS. So MIGS had a huge coming-out party at ASCRS, and it was great to see.
Dr. Steinert: Thus far, all of the MIGS has been combined with cataract surgery, yet we know that traditionally, most glaucoma surgery has been separate from cataract surgery. Are these microtechniques going to make their way into non-cataract surgery applications?
Dr. Samuelson: I think they will, but MIGS will probably continue to be centered around cataract surgery. In the past, we decoupled cataract and glaucoma surgery because after we learned that clear corneal phacoemulsification ("phaco") lowered pressure by itself in a large proportion of patients and retained all future surgical glaucoma options, we stopped doing combined procedures except for cases of extremely advanced disease or very high intraocular pressure. We were doing phaco alone for many years for mild to moderate glaucoma, but now that MIGS has evolved, we are using the phaco platform to provide an adjunct to the procedure by adding on a MIGS-plus type of procedure -- whether it is an iStent®, Trabectome®, or endoscopic cyclophotocoagulation.
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