Primary posterior capsulotomy and the femtosecond laser

Abstract

Al-Nashar and Khalil’s1 findings regarding the safety of primary posterior capsulotomy are consistent with other reports in the literature, as referenced in their paper. Indeed, Menapace2 analyzed 1000 consecutive cases and established the combination of posterior capsulorhexis with optic buttonholing as an alternative to standard in-the-bag intraocular lens (IOL) implantation. So why are we not performing primary posterior capsulorhexis or capsulotomy? There are probably several reasons, including the difficulty of the surgical technique. Many, and probably most surgeons if we were to be totally honest, are not confident in their ability to perform a consistent accurate posterior capsulorhexis. After all, for many surgeons, the only time they have performed this is in cases in which a posterior capsule complication has occurred. The femtosecond laser is a major technologic breakthrough for this purpose. It can be used to safely perform a primary posterior capsulotomy, as shown by the pioneering work of Dick and Schultz.3 In addition to use in adults, it can also be used in pediatric cases.4 Also, it can be used as a surgical fixation tool, as we showed with toric IOLs.5 This advance allows the surgeon the precision and sizing accuracy needed to consistently achieve excellent results. By offering a technique that can be performed by all surgeons in a safe way with a consistent result, the femtosecond laser might represent the first achievable solution for the most common complication of cataract surgery—posterior capsule opacification (PCO). Like cataracts, it slowly robs our patients of their best potential vision, and it is a costly waste of our healthcare financial resources. To accomplish this, more surgeons will have to use the laser in the operating room setting where it can best be integrated as a tool of surgery. The laser companies will have to recognize the opportunity before them and develop the software applications for posterior capsule treatment and have it approved as an indication for laser treatment. Reimbursement will have to be increased for the surgeon who performs the primary capsulotomy. These are difficult steps, but we owe it to our patients to pursue these goals and eliminate the complication of PCO.