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Lessons from the past can contribute to future success with femtosecond laser
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 Richard L. Lindstom |
The femtosecond laser is, to me, a precise computer-driven scalpel. Select surgeons can make more mechanical cutting tools, such as a microkeratome, metal or diamond blade, and cystotome or capsulorrhexis forceps, generate high-quality and reproducible incisions, but evidence is growing that most surgeons cannot duplicate the precision of a femtosecond laser when making a LASIK flap, a corneal relaxing incision, or a round and perfectly sized capsulorrhexis.
The precision and reproducible outcomes of a femtosecond laser-created flap from one patient to another, and from one surgeon to another, have encouraged the majority of surgeons in advanced countries to adopt this technology for LASIK. It is clear that select surgeons with significant experience can duplicate the outcomes achieved with the femtosecond laser using a mechanical microkeratome, but results generated in high-volume centers repeatedly confirm that better outcomes and lower complication rates are achieved when a femtosecond laser is adopted for LASIK surgery.
The lessons learned in corneal refractive surgery as femtosecond lasers were adopted likely hold some important lessons for those wondering about the future as femtosecond lasers are applied to refractive cataract surgery. Having participated personally in the transition to femtosecond laser-assisted LASIK in a private practice, Minnesota Eye Consultants, and also a large-volume multicenter group, TLC Vision, I would like to share a few observations.
There was even more skepticism that a femtosecond laser could make LASIK a better procedure than there is today regarding its application to cataract surgery. Critical constructive debate is to be encouraged, but so is an inquisitive and open mind that allows and even encourages new technology to be evaluated in an orderly fashion. There will always be innovators, early adopters, middle adopters, late adopters and non-adopters of new technology and techniques. Patience and an open, inquisitive mind are ever more needed, as change in our field continues to accelerate.
Still, it is important to remember and comforting to know that change does not occur overnight. We are now 13 years since the first femtosecond lasers were commercialized for LASIK flap making and really only at the middle of the adoption cycle. I suspect the same will be true of femtosecond laser refractive cataract surgery. It will take a decade or more for adoption to reach a high level, and along the way, many lessons will be learned to ease the transition for the middle and late adopter surgeon.
I am certain that the magic of competition will make the technology, surgical techniques and economic value proposition continuously better. In regard to economics, the value proposition for providing a patient with a high-quality lifestyle-enhancing refractive outcome with LASIK has settled into an economic range generally bracketed between $1,000 and $3,000 in the U.S. When a LASIK surgeon sits down to do a femtosecond custom excimer LASIK, he or she commands two lasers valued at $300,000 to $400,000 that require a per procedure click fee of $300 to $400. Is it possible for a 35-year-old myope to afford LASIK requiring such expensive technology? Millions of patients worldwide confirm the answer is a resounding yes. Is it possible for the ophthalmic surgeon to provide LASIK surgery requiring such expensive equipment at a cost that patients consider a reasonable value and still afford to practice the art? Here again, the answer is yes, but only if the volume of surgery per femtosecond and excimer laser is high enough to cover the fixed and variable costs. In general, a volume of 600 or more procedures achieves this goal.
Many business models have evolved to allow LASIK to be economically viable for the provider and a fair value for the patient. Very busy individual or group practices can afford their own lasers. Others need to share the technology in open-access laser centers. Some lower-volume users have turned to sharing lasers provided by corporations specializing in mobilizing the technology to allow shared access across large geographic areas. Today, any surgeon in America who is highly motivated to do laser corneal refractive surgery can find a way to enter the field with volumes as low as five to six procedures per month. I believe the same will be true for the femtosecond lasers designed to enhance refractive outcomes in cataract surgery. Surely, many of the generally much more affluent 70-year-olds are as capable of sharing in the cost of a lifestyle-enhancing refractive outcome as their 30-year-old myopic children with a lower net worth and children to feed and educate.
As an early adopter of laser corneal refractive surgery and now laser refractive cataract surgery, I see much similarity. My early results suggest that refractive outcomes can be enhanced with a combination of intraoperative keratoscopy, wavefront aberrometry and femtosecond laser-customized incisions. In addition, early adoption of this technology has helped position our practice as a high-tech/high-touch leader in refractive cataract surgery.
As we focus more energy on enhancing our patients’ refractive outcomes, we are seeing both our overall cataract volumes and also our conversion rate to the premium channel grow. For us, it is practice growth that supports investment in new technology, infrastructure and the caring employees required to create the proper environment to generate patient word-of-mouth referrals.
I believe it is a mistake to simply calculate a per procedure cost of a new technology and expect to make a profit on each individual patient. Decades ago I adopted refractive cataract surgery principles including on-axis small-incision cataract surgery, intraoperative corneal relaxing incisions, compulsive biometry and a willingness to enhance motivated patients, all at no charge, as a way to improve my patients’ outcomes, expecting that happier patients and referring doctors would generate practice growth. My experience firmly supports as a fact that better refractive outcomes grow practice volume. It worked 30 years ago, and it works today.