Femtosecond laser capsulotomy

I would like to commend Friedman et al.1 for reporting their interesting experience with an optical coherence tomography-guided femtosecond laser in cataract surgery. As discussed, precision of the capsulorhexis could improve the optical performance in cases of “premium” intraocular lenses (IOLs). In cases of monofocal IOL implantation, it remains to be demonstrated that the minimal difference in capsulorhexis size and shape found in this study would have a significant impact on the refractive outcome. To date, only 55% to 66% of eyes achieve a final refraction within 0.5 diopter of the target.2,3 More than the capsulorhexis, many other things can be the contributing factors. Although I agree that patient safety and the noninferiority of the femtosecond laser capsulotomy compared with the standard treatment have been verified, I have some concerns: Is this technology sustainable and affordable? Eyes with a “pupillary dilation of at least 7.0 mm, axial length between 22.0 mm and 26.0 mm, and anterior chamber depth greater than 2.5 mm” enrolled in this study represent the majority. Therefore, manual capsulorhexis would be required rarely, such as in cases of poor preoperative pupil dilation, if the femtosecond laser capsulorhexis were the standard. That might have a detrimental effect on surgical training. How and when would trainees gain experience in performing this delicate surgical step in cataract extraction? In recent years, we have joined other healthcare providers in demanding the most cost-effective, evidence-based treatment methods. In cataract surgery, the search for healthcare efficiency has led to exploration of the feasibility of simultaneous bilateral cataract surgery with a view to cost savings.4,5 I refer not only to the costs related to implementing lasers in our departments, but mainly to the costs that derive from “operating room floor time and staff time,” as recently investigated by Leivo et al.5