I am always happy to add new technologies to our surgery center and operating room because I like having more tools in my toolbox. But every new device has its set of potential complications and own learning curve. With a femtosecond laser the challenge is that the capsulotomy created in the anterior lens capsule is not as strong as a manually created capsulorhexis. This is because it has been created by using thousands of tiny laser spots which means the edge looks perforated like a postage stamp. Each of these spots could potentially run out and in the case presented here, that is exactly what happened. The intumescent white cataract also plays a role here since the capsular bag is pressurized. This experience caused our guest surgeon to proclaim, “I will never use the femto laser again for intumescent cataracts!” What do you think? Please comment below.
I’ve never bothered with a Femtosecond laser for cataract surgery because I believe that the things it does can be done faster, better more efficiently and more cost effectively by a reasonably skilled surgeon. Richard Hoffman once gave me this quote for a lecture I gave on this topic “The initial promise of FLACs was that it would make bad surgeons good and good surgeons great. My impression so far is that all it has done is made mediocre surgeons dangerous, and good surgeons . . . slow..” When surgeons do most of their cases with a Femto laser they lose a lot of information gained in performing those steps by hand that allow them to alter their approach for the better of the patient and they also lose the ability to deal with difficult and complex cases that require advancing the skill set they are relegating to the laser to perform for them. I see a lot of complications referred to me related to the laser and its use that I think could have been prevented with good manual technique. One of the more common problems I see is actually related to the cornea relaxing incisions and the creation of irregular astigmatism which progresses over time. I wish surgeons would stop doing these as they can be impossible to really and totally fix. (Steven Safran)