EyePod: Integrating cutting-edge pipeline devices for enhanced cataract surgery

Neda Shamie, MD, and Peter J. McDonnell, MD, discuss the evolving role of femtosecond laser-assisted cataract surgery (FLACS) in ophthalmology, highlighting its benefits in addressing corneal astigmatism, capsulotomy precision, and aiding complex cases, while acknowledging regional variations in patient interest and emphasizing the need for ongoing evaluation in the context of advancing premium lens technology.

The views and perspectives expressed are those of Dr. Shamie and Dr. McDonnell.

Audio transcript

Editor’s note: This transcript has been edited for clarity.

Sheryl Stevenson: Hi, everyone, and welcome to this episode of the Ophthalmology Times EyePod podcast series.

This is Sheryl Stevenson, group editorial director with the Eye Care Group here at MJH Life Sciences, and we are joined today by our co-chief medical editors from the West Coast to the East Coast.

Dr. Peter J. McDonnell is the director of the Wilmer Eye Institute at Johns Hopkins University School of Medicine in Baltimore, Maryland, and Dr. Neda Shamie is a cataract, LASIK, and corneal surgeon and partner of the Maloney-Shamie Vision Institute in Los Angeles, California, as well as an adjunct clinical professor of ophthalmology at the USC Keck School of Medicine.

In this episode, Dr. Neda Shamie and Dr. Peter McDonnell explore the current landscape of femtosecond laser-assisted cataract surgery, sharing insights on its integration into their practices, emphasizing its benefits in addressing corneal astigmatism, enhancing capsulotomy precision, and aiding in complex cases, while acknowledging regional variations in patient interest and the need for ongoing evaluation of its impact on outcomes and advancements in premium lens technology.

Let’s take a listen now…

Peter J. McDonnell, MD: Hi, it's Peter McDonnell, and we're here with the podcast on Ophthalmology Times where we're talking about the exciting new developments in our field of ophthalmology. I'm excited to be here with my co-chief medical editor, Dr. Neda Shamie.

Neda, femtosecond laser-assisted cataract surgery [FLACS]...That took the world by storm a few years ago and there been new developments in the last year or two in terms of pipeline of approved products. So, share with me where currently...where does femtosecond laser-assisted surgery fit in your practice?

Neda Shamie, MD: Well, thank you, Peter. It's great to be here with you again and having these kind of casual conversations about topics that are front and center in our practice.

I've been doing femtosecond laser cataract surgery for 12 years now. I initially started with LenSx and then had experience with the Catalys and then more recently have had experience with the Ally or the LENSAR laser.

In my practice, possibly because I'm in Los Angeles, West LA, the type of practice that I have where patients seek me out because of the premium offerings that we have, we have a large percentage of our patients who choose to have femtosecond laser surgery...more than the majority; it's close to 90-plus percent. As we know, laser cataract surgery has been approved for treatment of astigmatism. And so I make sure that if I am offering laser cataract surgery, it is in cases where the patient has corneal astigmatism that can be treated with the limbal-relaxing incisions that the laser can make.

Although I love the other steps of the surgery that the laser really has fine tuned and adds a level of precision that I say that, even as great of a surgeon as I am because I had the best mentor in Peter McDonnell, I still am not as good as a laser is. I love...I think femtosecond laser-enabled cataract surgery is a very elegant way of doing cataract surgery.

And there's controversy as to whether or not there are benefits. Most definitely, I think the benefit of addressing the corneal astigmatism in my hands...if it's less than one diopter I use the laser, .5 to about 1.25 or 1.5. I use a laser to create limbal-relaxing incisions that are very, very reliable and now with image guidance, perfectly positioned based on prior measurements preop.

But I also like the centration of the capsulotomy. I like the perfect sizing of the capsulotomy so that there is overlay of the lens implant. I like that it helps me in complex cases, or very dense cataracts. It softens the nucleus of the cataract such that, at least in my hands, I feel that it's a more reliable way of doing cataract surgery with the least amount of energy used. So it's great. I mean...currently with the Ally, I'm really enjoying the image guidance. The image guidance with the Ally laser, it's streamlined and it really allows me to feel comfortable with toric lens implantation and toric alignment because the Ally, based on image guidance using the Pentacam, creates these nubs in the capsulotomy so that I know exactly where the axis of the toric alignment should be. So that's my thought...my two cents on it.

McDonnell: Yeah, well, I have no financial interest in any of the companies that make this technology but I really like the technology. It's very impressive to me. We looked rigorously in our institution at things like endothelial cell counts and postoperative visual acuities, etc. between the femtosecond laser and 'traditional' phaco and could not find demonstrable advantages in most of these areas. Certainly, the centration and the circularity of the capsulorhexis is advantaged with the femtosecond laser, I think.

But it is interesting, you mentioned how, in certain markets, it's really valued by the population if you can offer this. And in our area, Baltimore and Washington, DC, are very interestingly very different markets in that regard. There's much greater interest in the national capital region in the laser-assisted surgery than there is in Baltimore. So, you know, it is a matter of being sensitive and responsive to the desires of the population in the area in which you live. And since you're in the Los Angeles area, it doesn't surprise me that that's probably something that a high percentage of the population values. So I think having that comfort with it and being able to offer it to the appropriate patients makes total sense.

Shamie: Yeah, absolutely. Obviously, one of the biggest hurdles is if you operate at a surgery center that does not have access to the laser it wouldn't be possible. I'm grateful and feel really privileged that in our surgery center we have one of each of the three lasers currently available to us. Our experience has been really positive with it.

But, as you said, the data doesn't speak as to anything that is of a significant difference as far as a benefit to the laser. And that's where the challenge is, is to really...how we decide to fit it into our practice really comes down to patient choice. I don't press it on our patients at all. This is a choice that the patients make. Our practice draws patients who are interested in advanced technology.

And then also, it's important to note that again it's not approved for anything other than correcting astigmatism.

So with that, there's a lot of information out there. I would love for the next generation of ophthalmologists to have at least some introduction to laser because my expectation is that there will be opportunities, especially in the premium lens sector, that there may be some benefits to using laser, if you're implanting a toric lens, if you're implanting premium lenses like presbyopia correcting lenses, as far as centration and tilt of the lens and maybe with data that can those kinds of differences can be elucidated.

McDonnell: Yeah, I agree with you. Once I think we have an accommodating lens that works really well that it may be necessary to pair that with a device like the femtosecond laser. So it's a fun field and I'm sure there'll be exciting progress and developments in the coming years. It'll be really fun to follow this along as we get more and more experienced with it.

Thanks, Neda. Great to talk with you.