BOOK REVIEW

‘Blade-free’ incisions  Femtosecond lasers (FSLs) are the big story in anterior segment surgery these days. A PubMed search of “femtosecond+LASIK†returns more than 250 results. “Femtosecond+cornea†provides more than 450 published articles. The 2011 annual meeting of the ESCRS had two entire free paper sessions dedicated exclusively to femtosecond laser applications. Despite the intense excitement surrounding this new treatment modality, the vast majority of anterior segment surgeons worldwide have never laid eyes on an actual FSL, much less used one to treat a patient. The FSL produces ultra-short pulses of near-infrared light whose duration is on the order of a femtosecond. Strong focusing of the beam concentrates the laser pulse to an extremely fine point. This compression of the laser pulse in both time and in space allows for the delivery of energy with great precision, reducing unintended or “collateral†destruction of surrounding tissues. The targeted tissue is photodisrupted by local vaporisation. Because the laser light is created at a near-infrared wavelength, the beam is not absorbed by optically clear tissue, allowing anterior chamber targeting at various depths. As the foreword notes, the FSL can create incision architecture in patterns not repeatable even by skilled surgeons. Drs Ashok Garg and Jorge Alio have decided to elucidate the recent advances and future possibilities of femtosecond laser-assisted surgery. In their new book, Femtosecond Laser – Techniques & Technology, the editors bring together more than two dozen specialists to help explain the various applications, both current and future, of FSL treatment of the anterior segment. Considering the fact that cataract surgery ranks among the most common surgical procedures worldwide, any significant changes in the way it might be practised can have wide-reaching consequences. Current FSL applications include several steps in cataract and corneal surgery. With endophthalmitis remaining the most feared complication of cataract surgery, FSL researchers have focused on developing better and safer “blade-free†incisions. The goal is to create highly precise, pre-calculated entry ports that will reduce wound gape and its associated problems. The next step in cataract surgery, the capsulorhexis, also lends itself to laser-assisted creation. The FSL can generate a strong, circular rhexis of a predetermined size.

The third step, phacoemulsification, can be a traumatic experience for intraocular structures, leading to peri-operative thermal damage and postoperative inflammation. It has been suggested that FSL-assisted phacofragmentation might decrease the average energy required to emulsify hard cataracts, although significant hard evidence is still in the making. The FSL has applications beyond cataract surgery. Indeed, it started with flap creation during LASIK and incision creation for the placement of intracorneal ring segments. Further corneal applications include the construction of an intrastromal pocket for riboflavin application via a 10-degree side cut prior to UV-crosslinking for keratoconus. Research is ongoing in this field and continues to drive new developments across a broad spectrum of applications. This book helps delineate the shift from “analog†to “digital†surgery, a movement from the ophthalmic surgeon as a mechanical machine to the surgeon as part programmer. The included DVD nicely illustrates this shift, with videos of 23 procedures.

This book is appropriate for anterior segment surgeons considering incorporating FSL surgery into their practice; for residents transitioning into fellowships that use the FSL; and for general ophthalmologists looking to get up to date on the current state of the art of this promising new tool.