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Weighing the benefits of femtosecond laser cataract surgery
Surgeons should consider all factors involved in implementation before diving in head first.
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More than 3 million Americans undergo cataract surgery each year, with more than half of them older than 65 years. In fact, cataract surgery as we know it today is one of the safest and most commonly performed surgeries in the United States.
Along with the rising number of cataract surgeries being performed, ophthalmologists face a number of new challenges. These include higher expectations from patients because cataract surgery is treated like refractive surgery, as well as the financial pressures of obtaining the advanced technology necessary to meet these expectations.
New technology
Recent surveys have shown that up to 70% of ophthalmologists say they are unlikely to perform femtosecond laser-assisted cataract surgery by the end of 2013, although a significant percentage of them want access to the technology. However, the financial burden involved with performing femtosecond laser cataract surgery makes it difficult for many surgeons to pull the trigger.
Our advanced IOL options, along with microincisional phacoemulsification and intraoperative wavefront aberrometry, such as the ORA System (WaveTec), provide more cost-effective premium alternatives to femtosecond laser cataract surgery while simultaneously providing excellent visual outcomes to patients. Realistically, most patients in our waiting rooms think laser has been used to remove cataracts for the last 20 years or so, anyway.
Mitchell A. Jackson
Nevertheless, premium surgeons want to remain progressive and bring more precision in visual predictability to patients’ already premium outcomes. They want to reduce complication rates in more challenging cases and drive the “wow factor” to the level already seen with most of our LASIK patients. In LASIK, femtosecond laser technology is already being used to create corneal flaps in the majority of cases performed in the U.S.
The learning curve
As with any new technology being introduced into the office or operating room, there is a learning curve and additional time associated with staff training, patient flow issues and the surgeon’s comfort level. The surgeon has to learn the individual docking procedure based on the platform chosen and, more importantly, how to minimize various complications, such as those associated with different cortex removal techniques and what to do in small pupil situations.
These are decisions to be made on factors such as where to place the femtosecond laser (ie, within the OR to create a one-step procedure for the patient, or outside the OR as a two-step procedure to help patient flow and efficiency), whether additional staff is needed (ie, a specific femtosecond surgeon just to create the flap), and what additional fees to charge the patient (ie, a standalone category for femto-related imaging per the new Centers for Medicare and Medicaid Services guidelines, or incorporated as an additional fee for astigmatism correction). Many surgeons are waiting for all these decisions to become clear before getting into the femtosecond laser cataract market for their patients.
Advantages
There have been many prospective, randomized and nonrandomized, and retrospective clinical studies on femtosecond laser cataract removal showing reduced effective phacoemulsification time; reduced complications typically seen with manual capsulotomies, such as anterior capsular tears; and improved effective lens position from consistent capsulotomy diameters. It is known that a 4-mm capsulotomy results in longer postoperative effective lens position than does a 6-mm capsulotomy for the type of IOL used, and inconsistent capsulotomy size can lead to inaccurate effective lens position and postsurgery refractions.
All of these clinical advantages of the femtosecond laser may eventually find their place, especially in cases involving the premium IOL patient, pseudoexfoliation syndrome, traumatic cataracts, and/or dense or mature cataract procedures. When the dust finally settles, surgeons will have to decide for themselves if the additional costs associated with femtosecond technology are worth the clinical advantages and the additional revenue stream generated.
Choosing a platform
Once the decision to purchase a femtosecond laser for cataract removal is made, the surgeon must decide among the various platforms. The biggest hurdle will be deciding the best purchasing model — such as full-price acquisition with a cost per procedure, or a “per-click” model with monthly and/or annual minimum procedures — that makes it affordable for the surgical center. Our surgical center initially acquired the ORA system as a more affordable investment. This has attracted other surgeons to the center and could potentially allow for a femtosecond laser purchase shared among many surgeons in the near future.
If the decision of which femtosecond laser to purchase is based purely on U.S. Food and Drug Administration approvals, the surgeon must realize that by the end of 2013, all platforms available in the U.S. market will have similar capabilities for corneal and arcuate incisions, anterior capsulotomy and lens fragmentation. The exceptions are the LenSx (Alcon Laboratories) and Victus (Bausch + Lomb Technolas) platforms, which both have additional corneal flap capability.
The femtosecond laser environment requires new visualization techniques, from manual, with the LenSx and Victus, to automatic, as with the Integral Guidance feature for the Catalys platform (OptiMedica) and the Augmented Reality system for the Lensar platform.
Patient interface design is critical in minimizing corneal folds to improve the rate of free-floating anterior capsulotomies, such as that seen with Liquid Optics (Catalys), SoftFit (LenSx), RoboCone (Lensar) and Dual Modality (Victus). The imaging associated with each platform is what the CMS’ ruling substantiates for additional patient billing. This includes the advanced 3-D optical coherence tomography imaging seen with Catalys, LenSx and Victus, and the 3-D Scheimpflug ray-tracing imaging seen with Lensar.
In the end, it is best for the surgeon to demonstrate appropriate due diligence before diving into the femtosecond laser cataract arena. From selection of the correct patient billing model to deciding on surgery center modifications and patient flow considerations, and from proper surgeon education and adaptation to the desired approved platform, all must be accounted for in the final decision-making process.
Stay tuned for my next installment, solving the “-osin” mystery.