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Cataract surgery ready for the transition to femtosecond laser, surgeon says
Patients will be prepared to pay higher prices for the advantages of laser, according to a surgeon.
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Femtosecond laser for cataract surgery is a powerful technology with several advantages that patients will perceive as added value and worth an additional cost, according to one surgeon.
“Once we are convinced that this is the way to go, patients will be easily convinced,” M. Alaa El-Danasoury, MD, said at the World Ophthalmology Congress in Abu Dhabi, United Arab Emirates.
“Patients come with a problem and want a solution,” he said. “They want to see better with minimal dependency on spectacles. They want safety, fast rehabilitation and the best surgical outcome. Last but not least, they want affordable costs.”
M. Alaa El-Danasoury
The currently available solution is modern phacoemulsification with IOL implantation. Phaco provides excellent clinical outcomes with a relatively low risk profile and a short surgical duration. Except for premium lenses, the cost is mostly covered by third-party payers, either by national health care systems or health insurance providers.
Room for improvement
“Looking at the literature, we find the best we are offering to our patients today is 20/40 or 20/30 uncorrected. The majority of patients are depending on spectacles for near vision, even if premium IOLs are used. We are still far from where we want to be,” El-Danasoury said.
He noted that 20 years ago, when radial keratotomy and keratomileusis in situ were used in refractive surgery, surgeons thought they were performing state-of-the-art procedures. They were reporting results around 20/40 or better, within ±1 D of intended correction, and were very pleased with those results and happy to achieve them in about 90% of patients. Today, these results would no longer be acceptable, he said.
“The same is happening now with cataract surgery. We can do better and want to do better,” El-Danasoury said.
Laser use
The new technology, however, still must prove to be safer than phaco. It has been demonstrated to be safe in early reports, but larger studies with longer follow-up must prove that it is safer. In the same way, it must prove to be superior for premium IOLs, both multifocal and toric.
“We are assuming that it is better, because it allows better positioning and centration thanks to the higher reproducibility, predictability and accuracy of laser capsulotomy. We are also assuming that this will lead to significantly better visual outcomes, with good vision at all distances and more spectacle independence. But also, to confirm this, we need further studies,” El-Danasoury said.
Increased safety should result from the new technique of lens fragmentation, which is the most problematic part of cataract surgery. With laser energy replacing ultrasound energy, the traumatic impact on the eye is decreased. Ultrasound-related risks and postoperative complications are avoided.
“What we have proved so far is that we do save on phaco energy and phaco time,” El-Danasoury said.
Laser incisions, which are completely self-sealing, should likewise lead to increased safety compared to manual incisions, he said.
The cost of the procedure remains a major issue. There is an estimated additional cost of $1,000, which includes the laser acquisition, per-click fee and additional chair time.
“When I started doing femto-LASIK, I realized I had to spend more time with my patients to explain why this technology is a better one,” El-Danasoury said. “Today my LASIK is 100% femto. I no longer need to compare techniques and prices because patients come specifically to have this procedure at a given cost that is now well-established.”
When the laser is involved, persuading patients is easy, he said. They clearly perceive the greater precision and reproducibility of laser as an advantage.
“Patients perceive the laser as magic, at least in our region. They don’t think of laser as surgery, although you explain to them that at least in the case of cataract, it is surgery as much as regular phaco is,” he said.
El-Danasoury will soon be performing femtosecond laser cataract surgery in his practice. In the meantime, he is asking his patients how they feel about the extra cost of the procedure.
“I have mixed results, but more than half of my patients say they’d be willing to pay for a laser procedure,” he said.
He thinks that the transition to femtosecond-assisted cataract surgery will happen naturally, as it happened for femtosecond LASIK.
“The only concern I have is that industry and adverts may increase patient expectations beyond proven results, as it happened with the illusion of ‘eagle vision’ in the early days of customized ablation. We need to watch this to avoid having to deal with patients’ disappointment and dissatisfaction,” he said. – by Michela Cimberle
Perspective
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Michael Lawless, MD
What this article signifies is that this new, potentially better way of performing cataract surgery is gaining worldwide traction. El-Danasoury decided to incorporate femtosecond laser cataract surgery into his practice. Such a decision can be quite confronting for an ophthalmologist who is comfortable with his current manual cataract surgery. He will need to incorporate a new machine, new staff and also learn a new technique, and fit all this into an already busy practice. What percentage of patients elect to proceed with laser as opposed to manual cataract surgery will be influenced by a range of factors but mainly by the enthusiasm of the individual surgeon and his/her belief that it is a better way to perform surgery.
Interestingly, El-Danasoury has also canvassed the views of patients, and they have responded positively to the promise of precision and safety that a laser-based approach can potentially offer. He draws an analogy with the transition from mechanical microkeratome to femto-LASIK, and I think this is a more apt analogy than comparing laser cataract to the introduction of phacoemulsification.
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