Refractive Femtosecond Laser

There are many different femtosecond laser surgical platforms to choose from, and it can be hard to keep them all straight. We have prepared a table allowing you to compare these at a glance, along with some comments from some of our members who use these lasers regularly.

Béatrice Cochener-Lamard MD, PhD on the ELITA Femtosecond Laser by Johnson & Johnson Vision (J&J).

“After many years of using lenticule extraction surgery, we are now seeking new strategies in refractive surgery, aiming to transform the procedure from a product to a true concept. As one of the biggest fans of lenticule extraction surgery with SMILE, I was contacted by J&J—a pioneer in femtosecond laser—and asked to become one of the European investigators for their new platform called ELITA.”

One of the main features of ELITA Femtosecond Laser is the new proprietary procedure of lenticule extraction, smooth incision lenticule keratomileusis (SILK). According to Prof Cochener-Lamard, ELITA is providing the same outcome in terms of safety and efficacy compared to the VisuMax 800 (SMILE) platform, with a visual recovery of two to four days and a short learning curve. The specificities are based on the biconvex profile of the lenticule, which receives half of the correction on each side, extended by a thin layer addition “flat-add” at the periphery that facilitates the removal of the lenticule.

“We have no intraoperative complications to report after more than 150 cases performed in our centre. The treatment nomogram integrates corrections of spherical aberrations, compensation of the applanation effect, and transition zones. Like all the other recent KLEx devices, the machine offers adjustable centration and compensation of cyclotorsion thanks to an interactive screen.”

The ELITA platform is on an ongoing trial in 50 centres. It was approved by the US FDA and recently validated with the CE mark.

Francesco Carones MD on Alcon WaveLight^® FS200 Femtosecond Laser.

A valid and easy-to-use device, the FS200 by Alcon WaveLight^® allows the surgeon to perform LASIK procedures, corneal inlays, and intrastromal channels for segments.

“This device always keeps paying off. After 10 years of continuous use, I never encountered a single major issue. Never a poorly cut flap, nor the need to stop mid-procedure.”

The FS200 stands out for the two-stage suction system: while the first part applies a vacuum between the suction ring and the patient’s limbus, the second stage connects the suction ring and the applanation cone. With this, the eye remains very still, creating a wonderful stabilisation both for the alignment phase and the procedure. It might not be very easy to perform at first and may require a little practice, he observed.

Another important feature of the FS200 is the ability to customise, adapt, and modify data, even after the suction phase. Dr Carones noted it is not necessary to centre before this phase. If a decentration is detected, the only way to fix the issue is to repeat the alignment. On the contrary, the FS200 makes it possible to adjust via software by calibrating the X and Y axes and the cyclotorsion right on the spot.

The FS200 is fast, creating an 8.5/9.0 mm flap in 9 to 12 seconds, which Dr Carones said could be further improved with a quicker scan time. It would also benefit from the implementation of a remote assistance service, he noted.

Antonio Leccisotti MD, PhD, MSc, FWCRS on FEMTO LDV Z8, Ziemer.

“I have operated around 100,000 eyes performing LASIK and femto-LASIK in my career—of which I conducted at least 90,000 with the FEMTO LDV Z8 by Ziemer. This is a device that always provided optimal flaps, very few losses of suction, almost no cases of DLK, but especially smooth cut surfaces every single time. It is the most advanced instrument in our armamentarium.”

The LDV Z8 features a moveable and articulated arm that can be placed over the patient, bringing the machine close to the eye and not vice versa. This provides better handling of the device, allowing a swift switch from a femto to the excimer laser, like in the case of a LASIK procedure, he suggested. Moreover, LDV Z8 also comes with an integrated intraoperative OCT scan acting as guidance and providing information during surgery and an automatic centration/ alignment option, very useful in KLEx.

What makes this device special is also the laser, Dr Leccisotti explained. Set at low energy and with small, narrow impulses, it can create a very smooth surface, sensibly improving precision and refractive outcomes. Along with LASIK, cataract, intrastro­mal lens, and corneal transplants, the LDV Z8 provides the surgeon with the means to perform CLEAR, an application enabling a safe and fast KLEx. It is also “a wonderful machine for lenticule extraction,” he observed.

He commented the laser velocity is a little slow when it needs to perform the cut. But the device overall is safe and effective and so simple to use—it could be used in training.

Roberto Bellucci MD on Bausch + Lomb VICTUS^®.

“I have a long experience with the VICTUS device by Bausch + Lomb. I started using it in 2012 for cataract and LASIK surgery, and I am still using it today.”

A great fan of VICTUS, Dr Bellucci considers it an incredibly versatile device for LASIK, capable of “making even a cup of coffee if the surgeon requires it, so to speak,” he complimented with a bit of humour.

As a pre-KLEx generation femtosecond laser, it is an extremely adaptable instrument, capable of doing almost everything, from LASIK to cataract, astigmatic cuts, intrastromal rings, and corneal transplants in a very reliable and safe manner, Dr Bellucci observed. It is very fast by today’s standards, able to cut a flap in less than 20 seconds.

VICTUS features an intraoperative camera and OCT that gives the surgeon the possibility to observe corneal flap formation from different perspectives.

“You can observe the thin line of bubbles forming in real time and [the depth of] the cut, a beautiful feature that can have maybe less use in LASIK than in cataract, but it is a fascinating spectacle on its own.”

One of the strongest points of VICTUS, Dr Bellucci noted, is the suction ring. Although separated from the device, it can be applied with a little help from intraoperative microscopy. The ring is placed on the perilimbal conjunctiva and has a two-phase suction, adjustable to maximise precision. Surgeons can centre their procedure on the clip, but with VICTUS, they can also move the clip if the centration is insufficient.

Ivan Gabrić MD on SCHWIND ATOS femtosecond laser.

“We always thought KLEx would never be a match for LASIK, as the early visual recovery was measured on days, not hours. Also, with the lack of cyclotorsion control with previous generation devices, it was not great for high astigmatic corrections. We thought lenticule procedures will always take longer to recover. However, with the SCHWIND ATOS femtosecond laser, each challenge fell apart quickly. KLEx is not a difficult surgery anymore, and with properly optimised laser settings and surgical techniques, more than 95% of patients have monocular vision of 20/20 or better on day one.”

One of the best features of ATOS is customisation, Dr Gabrić said.

“Everything can be surgeon-tailored, making every little desired change in settings, including optical zones of up to 8.0 mm. It can be a little challenging and overwhelming for inexperienced users at first, but after a dozen cases, it’s easy. Docking is semi-automated and amazingly easy and fast to achieve, and the device allows a KLEx with zero lenticule thickness edge for safer removal.”

Moreover, he reported integration of other external diagnostic hardware and software is possible and simple. It can be a little slow in the warmup and the energy check, but once the laser fires, it is quick.

Simonetta Morselli MD on ZEISS VisuMax 500 and 800.

“VisuMax by Zeiss is the first femtosecond laser of this new generation. It is a trailblazer and the first device allowing the surgeon to perform lenticular surgery, the original ReLex SMILE. I have been using this device since its release in 2012.”

VisuMax has all the features required for a highly customisable refractive surgery, with a very versatile laser that provides all the options for a personalised LASIK and KLEx—by selecting flap thickness, depth of residual posterior stroma, and myopia correction from -0.50 D to -10.0 D with -5.0 D of astigmatism, she noted.

The laser is still a bit slow on the SMILE side, with 32 seconds of suction time, Dr Morselli observed, but that improved in the VisuMax 800. Despite some issues related to cyclotorsion and posterior centration, she said it is a versatile device that reliably offers access to every desired procedure.