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How will surgeons offset the additional expense of femtosecond lasers for cataract surgery in the ASC?
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Cost, market factors will slow rise of femtosecond cataract surgery
 Randall J. Olson |
I predict femtosecond cataract surgery will be a big player in ophthalmology. That said, cost is a definite barrier because anyone who believes that there is more money coming for cataract surgery in the future is mistaken. Cataract fees will be lucky to keep pace with inflation. For this reason we have a paradox, because femtosecond cataract companies are not going to give this away. It will become mandatory to compete in the premium IOL market in the future, I predict. Because this is direct-to-consumer, subsuming these costs in the procedure should be a no-brainer. The issue is, most ophthalmologists do not have enough refractive IOL/premium IOL volume to support this new toy.
Will that always be so? With new products such as femtosecond laser for cataract, there is no reason to expect that this whole lenticular refractive market could not be much bigger. Charlie Kelman, not long before he died, said that we would see the refractive lenticular market dwarf the cataract market someday. This is very possible.
Another area where this can immediately make a major impact is in the correction of astigmatism. I predict that femtosecond incisional accuracy and utility mean we have barely scratched the surface on what is possible. Having to charge to use this device to correct astigmatism with all its utilities and safety-enhancing features does not seem to be a tough sell to me, and this we can do with cataract patients today. We may start a bit slow, but smart people in our field will figure this out. I see plenty of avenues to move forward so that soon there will be a rush to adopt. I think it is not a question of if but when.
Randall J. Olson, MD, is an OSN Cataract Surgery Board Member.
More expensive technology more cost-effective, self-supporting
 Roger F. Steinert |
In assessing the financial issues of medical technology, the central question is not about cost but rather cost-effectiveness. Without question, adding the femtosecond laser to cataract surgery will increase cost. In the 1980s, there was an intense debate that lasted a decade about whether ultrasonic phaco, with attendant complexity and cost, was any better than extracapsular cataract extraction, especially when ECCE was performed inexpensively with a manual irrigation and aspiration technique. The better results with small incisions, enabled by the simultaneous improvement in foldable IOLs, slowly led to a consensus that is now essentially unanimous. The more costly and complex technology was, indeed, more cost-effective.
Similarly, the more expensive and complex excimer laser supplanted the much less costly radial keratotomy. Currently, a similar shift has occurred with femtosecond laser flaps in LASIK, but the final decision about cost-effectiveness has not yet been rendered by the market, with both laser and blade technologies having roughly even usage. I predict that when the economy recovers, however, the cost-effectiveness of the femtosecond laser flaps will win out because the cost can be accommodated.
Femtosecond-assisted cataract surgery is still in its infancy. We are witnessing the birth of an entirely new sophisticated technology, with three expert teams competing in development. Once these systems begin to enter the market, surgical techniques will emerge that we are only beginning to imagine. Ultimately, the technology has the potential to reshape our approach to the IOL itself, just as ultrasonic phaco stimulated the shift from cheaper hard PMMA to more expensive but more effective silicone and acrylic. Think of injectable implants.
Initially, the premium IOL channel will allow surgeons to cover the added cost of the femtosecond laser technology. Patients have been asking for laser cataract surgery for 40 years. The creativity that will follow should change the field of cataract surgery over the next decade. In the meantime, you can expect that many words will be written and spoken in passionate debate on these issues.
Roger F. Steinert, MD, is an OSN Cornea/External Disease Board Member.