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- W2409261036 abstract "We thank Zygoura et al for their comments on our report, “Management of Small Pupils in Femtosecond-assisted Cataract Surgery Pretreatment.” The authors are concerned about the femtosecond laser (FSL) because it may impact operating room setup and time efficiency (i.e., whether FSL is available in the same operating room as phacoemulsification), and this is an important aspect of FSL-assisted cataract extraction. With the introduction of FSL, the cataract removal operation changes significantly; the FSL adds a step to the traditional phacoemulsification procedure and it is expected that overall operative time per patient will increase. Currently, there are no reports that quantify the time differences between FSL-assisted cataract extraction and traditional phacoemulsification. Unfortunately, we did not measure operative time in our study.1Kankariya V.P. Diakonis V.F. Yoo S.H. et al.Management of small pupils in femtosecond-assisted cataract surgery pretreatment.Ophthalmology. 2013; 120: 2359-2360Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar We are currently conducting a study comparing operative times between the 2 procedures and we hope to answer this important question. In our institution, the FSL is housed in the same operating room as phacoemulsification. We find this approach convenient and time efficient at this time; however, we need to assess a setup with the FSL placed in another operating room and determine the impact on time efficiency and patient flow. Femtosecond laser cataract surgery is a 2-step operative approach; as such, we need to determine the most efficient way to utilize this technology with the goal of improved patient flow. We also need to consider that most studies in the literature present the outcomes of FSL-assisted cataract extraction of experienced surgeons. To assess the cost-effectiveness and safety concerns associated with FSL, inexperienced surgeons need to be included in studies as well. An experienced surgeon is not likely to improve significantly his or her outcomes by using FSL. Inexperienced surgeons, however, may benefit from learning this technology. Additionally, to assess the cost effectiveness of the 2 procedures, we need to evaluate refractive outcomes and take into account the ability of FSL to effect rhexis and phacolysis in cases where it would be difficult to perform manually (e.g., pseudoexfoliation, mature cataracts, pediatric cataracts, and intumescent cataracts). Pretreatment with FSL may provide superior rhexis outcomes, reduce the effective phacoemulsification time, and reduce surgically induced zonular stress by reducing extensive intraoperative manipulations (by avoiding nucleotomy maneuvers). All patients included in our study1Kankariya V.P. Diakonis V.F. Yoo S.H. et al.Management of small pupils in femtosecond-assisted cataract surgery pretreatment.Ophthalmology. 2013; 120: 2359-2360Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar signed a standard consent form for cataract surgery and the use of FSL technology. In these patients, the anterior chamber had been entered before FSL application and there was a shift from sterile conditions (draped eye) to a sterile, nondraped setup (FSL application). It is important to note that the FSL cone apparatus and the balanced salt solution used as a liquid medium are sterile. For phacoemulsification, we returned to a sterile, draped setup for. We believe that, if asepsis is maintained, this approach may not increase the risk of endophthalmitis. Further studies are necessary to draw better conclusions. Dick and Schultz2Burkhard Dick H. Schultz T. Laser-assisted cataract surgery in small pupils using mechanical dilation devices.J Refract Surg. 2013; 29: 858-862PubMed Google Scholar reported on 73 eyes that had no postoperative complications associated with FSL, including endophthalmitis. They also describe the feasibility of FSL in patients with small pupils and the operative approaches necessary to accomplish cataract extraction. Despite our data1Kankariya V.P. Diakonis V.F. Yoo S.H. et al.Management of small pupils in femtosecond-assisted cataract surgery pretreatment.Ophthalmology. 2013; 120: 2359-2360Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar and those from Dick and Schultz,2Burkhard Dick H. Schultz T. Laser-assisted cataract surgery in small pupils using mechanical dilation devices.J Refract Surg. 2013; 29: 858-862PubMed Google Scholar the manufacturer advises against using FSL in patients with small pupils. In is important to adjust the operative approach and carefully plan the procedure to avoid complications such as air bubbles in the anterior chamber, which may interfere with the intended treatment. The question of which technique is superior—FSL or traditional phacoemulsification—remains undecided. Long-term, randomized, controlled trials are needed. Our institute has several ongoing studies to assess efficacy, safety, refractive outcomes, and complications of FLS. Kankariya et al.: Management of small pupils in femtosecond-assisted cataract surgery pretreatment (Ophthalmology 2013;120:2359-60)OphthalmologyVol. 121Issue 9PreviewWe read with interest the recent report from Kankariya et al regarding the management of patients with small pupils in the setting of femtosecond laser-assisted cataract surgery (LCS).1 The authors explored the feasibility of the procedure in eyes with small pupils. They adopted pharmacologic or pupil expansion techniques, and the femtosecond laser procedure was then performed. The anterior chamber was filled with an ophthalmic viscosurgical device before the laser procedure. Full-Text PDF" @default.
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