Zusammenfassung
Hintergrund
Der Femtosekundenlaser (FSL) hält zunehmend Einzug in die moderne Kataraktchirurgie. Als potenzielle Vorteile gegenüber der manuellen Standardchirurgie werden die höhere Präzision und Reproduzierbarkeit der Schnittführung und der Kapseleröffnung sowie die Reduktion der Ultraschallenergie für die Kernaufarbeitung angeführt. Durch die exakte Dimensionierung der Kapselöffnung sollen auch Dezentrierung und Verkippung der Kunstlinsenoptik verringert und die Zielrefraktion besser getroffen werden. Zusammen mit der Möglichkeit der Korrektur niedriger Hornhautastigmatismen durch Bogeninzisionen in der Hornhaut soll der FSL die Kataraktoperation von einem rein kurativen in einen refraktiven Eingriff überführen.
Methoden
Neben den eigenen Erfahrungen analysiert dieser Übersichtbeitrag kritisch die Beobachtungen von verschiedenen anderen Operateuren und Geräten bei der Ausführung laserassistierter Kataraktoperationen sowie die bis dato in Wort und Schrift publizierten Ergebnisse. Es werden die Vor- und Nachteile im Hinblick auf das chirurgische und refraktive Ergebnis analysiert und den über mehrere Jahrzehnte gesammelten Erfahrungen mit der manuellen Kataraktchirurgie gegenübergestellt. Zudem werden auch ökonomische und gesundheitspolitische Aspekte angeführt.
Ergebnisse
Die FSL-Kataraktchirurgie erhöht die Präzision und Reproduzierbarkeit der Zugangsschnitte und der Kapseleröffnung und vermindert die für die Kernaufarbeitung erforderliche Ultraschallenergie. Der klinische Nutzen wird allerdings durch die nachträglichen chirurgischen Manipulationen der Inzisionen (Linsenaspiration, Kunstlinseninjektion), durch die fehlende Darstellbarkeit des Linsenäquators für eine durchweg perfekte Zentrierung der Kapsulotomie auf die Kunstlinsenoptik und die geringe Bedeutung der Ultraschallenergie für das Hornhautendothel relativiert – dies vor allem vor dem Hintergrund der hohen Kosten. Demgegenüber treten Einrisse des vorderen Kapselrandes als wirklich relevante Komplikation mit dem FSL zumindest derzeit noch deutlich häufiger auf. Aus ökonomischer und gesundheitspolitischer Sicht ist die mögliche Übernahme der Kataraktchirurgie als standardisierbarem und extrem häufig durchgeführtem Eingriff durch die Industrie oder Investoren zu bedenken, was die derzeitigen dezentralisierten und individualisierten Strukturen und in der Folge die Patientenströme grundlegend verändern und den Chirurgen weitgehend abhängig oder überflüssig machen könnte.
Abstract
Background
The use of femtosecond lasers (FSL) is increasingly spreading in cataract surgery. Potential advantages over standard manual cataract surgery are the superior precision of corneal incisions and capsular openings as well as the reduction of ultrasound energy for lens nucleus work-up. Exact positioning and dimensioning of the anterior capsular opening should help reduce decentration and tilt of the intraocular lens (IOL) optics and thus achieve better target refraction. Together with the possibility to correct low-grade corneal astigmatism by precise arcuate incision, FSL technology is expected to convert cataract surgery from a purely curative into a refractive procedure.
Methods
Apart from own experiences this review article critically analyses the pertinent literature published so far as well as congress presentations and personal reports of other FSL surgeons. The advantages and disadvantages are scrutinized with regard to their impact on the surgical and refractive results and compared with those experienced by the authors with manual cataract surgery over several decades. Economic and healthcare political aspects are also addressed.
Results
The use of FSL surgery improves the precision and reproducibility of corneal incisions and the capsular opening and reduces the amount of ultrasound energy required for lens nucleus work-up. However, the clinical benefits must be put into perspective due to the subsequent surgical manipulation of the incisions (during lens emulsification, aspiration and IOL injection), the lacking possibility to visualize the crystalline lens equator as the reference for correct capsulotomy centration and the relativity of ultrasound energy consumption on the corneal endothelial trauma. This is of particular relevance against the background of the significantly higher costs. Conversely, tears of the anterior capsule edge which, apart from interfering with correct IOL positioning, may entail serious complications presently occur more frequently with all FSL instruments. From the economic and healthcare political viewpoint, thought should be given to the possible acquisition of the cataract surgical business by the industry or investors, as cataract surgery is a high-volume standardized procedure with enormous future potential. This could fundamentally change our currently decentralized and individualized structures and subsequently the steam of patient and make surgeons largely dependent or superfluous.
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Interessenkonflikt. R. Menapace und H.B. Dick geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Menapace, R., Dick, H. Femtosekundenlaser in der Kataraktchirurgie. Ophthalmologe 111, 624–637 (2014). https://doi.org/10.1007/s00347-014-3032-1
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DOI: https://doi.org/10.1007/s00347-014-3032-1