Femtosecond zigzag incision PK shows better results than conventional incision PK

The femtosecond procedure is more costly, but a new CPT code could pave the way for higher reimbursements.

Femtosecond laser zigzag incision penetrating keratoplasty resulted in faster recovery of best corrected visual acuity and less induced astigmatism than conventional blade trephination incision penetrating keratoplasty, a study showed.

Roger F. Steinert, MD, along with Marjan Farid, MD, and colleagues, conducted a retrospective study comparing two incision procedures in PK. They found that the zigzag-shaped femtosecond laser incision for corneal transplants provided an average of 1.5 D less astigmatism than the conventional blade trephination incision technique.

However, although recovery time was shorter and visual acuity was better with the femtosecond laser zigzag incision, it is a more labor-intensive and expensive technique than the conventional blade incision, Dr. Steinert told Ocular Surgery News. Surgeons in the U.S. do not receive adequate reimbursement for the additional work required with the procedure, he said.

“I think for the United States, at least, the biggest challenge is the fact that this clearly involves a significant increase in work and surgeon expertise, and it involves an increase in physical expense because of the cost of the laser,” Dr. Steinert, an OSN Cornea/External Disease Board Member, said. “What we’re doing is trying to get … enough other people to do these studies that we can be in a position to then make an application for a new [Current Procedural Terminology] code with an appropriately higher reimbursement.”

Study results

The study looked at 66 eyes of 57 patients. Of those eyes, 49 underwent femtosecond laser zigzag incision pattern PK, and 17 underwent contemporaneous conventional Barron suction trephination PK. Incisions were closed with a 24-bite running nylon suture technique. Follow-up in the study was 1 month to 1 year.

Results showed a significant difference in average postoperative astigmatism at 1 month (P = .013) and 3 months (P = .018). At 3 months follow-up, average astigmatism was 3 D for the zigzag incision group and 4.46 D for the conventional incision group, the study found.

For patients in the study with normal macular and optic nerve function, 81% in the zigzag group achieved BCVA of 20/40 or better at 3 months, whereas 45% of the conventional group achieved BCVA of 20/40 or better at 3 months.

“We had a much higher [BCVA for the zigzag incision procedure] in the subsequent months, like month 3 and month 6 at the 20/25 and 20/20 level and 20/30 level, compared to the conventional transplants at each of those time intervals,” Dr. Steinert said.

He said that the study demonstrated that full-thickness corneal transplants could be a successful option for some patients. Many physicians have not recommended the procedure because of issues associated with it, including longer postoperative visual recovery time or the need for high astigmatism-correcting glasses that cause distortion, he said.

“We haven’t achieved perfection, by any means. But I think that we’ve at least elevated the frequency of a very good outcome for a patient into the much more common, into the realm where it’s the expected outcome, not the unusual outcome,” he said.

Cost difference

Although results of the study showed that the zigzag incision technique was more effective than the conventional blade technique, the increased price of the procedure is an important consideration when choosing options, Dr. Steinert said.

“Basic economic realities have to be faced here,” he said. “I think we’re obligated, as physicians and surgeons, to always try to do the best thing for our patients. But we’re also obligated to get reasonable reimbursement for the work being done and the outcome being delivered.”

Two approaches could be used to perform the procedure, Dr. Steinert said. Seeking a new CPT code while using current codes is one approach, while the other approach considers the zigzag incision technique a “refractive component” in regular corneal transplants, he said.

The refractive component approach allows the procedure to be considered the same as a premium IOL procedure, Dr. Steinert said. In those situations, physicians would obtain an advanced beneficiary notice, charging extra for the refractive element of the transplant operation, he said.

“Different surgeons and different billing consultants have different philosophies about those two approaches,” he said. “I think anyone who is interested in this from a patient-care point of view and believes it would give patients better outcome needs to explore, in their own region and with their own Medicare carrier and their own billing consultants, which of those two approaches looks like it is the one to go with.” – by Erin L. Boyle

Reference:

• Farid M, Steinert RF, Gaster RN, Chamberlain W, Lin A. Comparison of penetrating keratoplasty performed with a femtosecond laser zig-zag incision versus conventional blade trephination. Ophthalmology. 2009;116(9):1638-1643.

• Roger F. Steinert, MD, can be reached at the Gavin Herbert Eye Institute at University of California, Irvine, 118 Med Surge I, Irvine, CA 92697-4375; 949-824-8089; fax: 949-824-4015; e-mail: steinert@uci.edu.

Dr. Steinert presents an interesting concept combining refractive surgery with traditional full-thickness corneal transplantation. The refractive component would be the femtosecond laser designer cut of the donor and the recipient edge to minimize astigmatism. We as physicians need to be cost-conscious and certain that the patients are receiving the premium value of the new technique. If the femtosecond laser proves over time to reduce astigmatism in patients receiving full thickness corneal transplantation, then it is reasonable to ask patients to pay for that premium.

– Richard J. Duffey, MD
OSN Refractive Surgery Board Member