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Making the decision to transition to laser cataract surgery
One surgeon describes how he and other local surgeons have thought through the tough decision.
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We stand poised on the brink of another femtosecond laser revolution. Just as femtosecond lasers surpassed microkeratome technology in corneal refractive surgery, I suspect we will see the same trajectory in refractive cataract surgery, as well.
No matter how convinced you are of the benefits, however, how and when to make the jump into laser-assisted cataract surgery is a tough decision. We are still in the early stages of this transition, and a femtosecond laser is an expensive capital investment.
Many surgeons have shied away from a laser purchase due to regulatory uncertainty. However, a November 2012 ruling from the Centers for Medicare and Medicaid Services went a long way toward clarifying the regulatory environment. The CMS ruling says that surgeons can charge for imaging services performed with the femtosecond platform in the context of premium IOL surgery, but we cannot simply charge for improving covered components of the surgery, such as the capsulorrhexis and lens removal. Patients can also be charged for the correction of corneal astigmatism, which is a non-covered service regardless of IOL choice.
Douglas A. Katsev
I am fortunate because a large group of anterior segment surgeons in my community of Santa Barbara, Calif., will be making this decision jointly for the surgery center that we all use. In the United States, femtosecond lasers approved for cataract surgery indications include the iFS (Abbott Medical Optics), LenSx (Alcon), Catalys (OptiMedica), LensAR (LensAR) and Victus (Bausch + Lomb Technolas). As we weigh our options, the following “Cs” will play into our decision.
Cost
Now that the regulatory environment has been clarified, it is time to crunch the numbers. The current options vary in price, and the cost-per-case is highly dependent on how many cases per month for which one will use it.
For example, by my estimate, a practice performing 1,000 procedures per year, with a 25% premium IOL conversion rate, could take up to 5 years to break even on a new femtosecond laser. Higher- or lower-volume surgeons would have to adjust their calculations accordingly. Obviously we would all prefer to get to the break-even point sooner and still be able to charge patients a reasonable and sustainable rate.
Clinical value
The goals of laser-assisted cataract surgery include an entry wound that is predictable, seals better and induces no astigmatism; a perfect capsulorrhexis that ensures accurate lens position; a softer, pre-divided lens that is easier to remove; and more precise and more customizable correction of astigmatism. Right now we are only part of the way there.
It is difficult to compare the performance of all of the platforms toward these goals. We have the most data, both good and bad, on the LenSx because it was the first comprehensive laser-assisted cataract surgery platform to be commercially available. Even today a new applanation contact lens seems to be improving results with LenSx.
We also know a great deal about how the iFS performs for the corneal components of cataract surgery, but it does not at present appear that it will be able to treat the cataract (rhexis or division of lens). Finally, the Catalys seems to work well inside the eye.
As these platforms continue to evolve, we may see clearer differentiation among the various systems that will increase confidence about generating better outcomes.
Capabilities
Surgeons must decide whether they will use a new femtosecond laser only for cataract surgery applications or if a dual-use laser with flap-making and other corneal applications is desirable. In my opinion, the ability to make good arcuate incisions, which is one of the major indications for reimbursement in laser-assisted cataract surgery, is critical; however, most of the lasers are either not approved for or are not getting rave reviews for their arcuate incision capabilities.
Corneal features may become an even more important consideration as presbyopia-correcting inlays, which are implanted in a stromal pocket, are introduced in the U.S. The challenge is that no laser is approved for every indication, nor is any single laser likely to be best at every feature.
Competition
In our market, we are fortunate not to be directly competing with anyone who is currently advertising laser cataract surgery, which means we can take our time making the best decision. Surgeons in larger or more competitive markets may have to weigh local conditions more heavily in their own decision making.
Current options
There are essentially three ways to proceed. Currently, the only commercially available, full-featured laser-assisted cataract surgery platform is the LenSx laser. Anyone who feels they must jump into lens-based surgery immediately might make that choice. Others may prefer to wait and see what the clinical results are with the Catalys, Victus or LensAR lasers as they are launched in the marketplace.
A third and reasonable choice for anyone who also does refractive surgery is to defer selection of a lens-based laser and begin performing the corneal components of laser cataract surgery, such as entry wounds and arcuate incisions, now. Even for those using an earlier-generation IntraLase (Abbott Medical Optics), the upgrade to iFS is still cost-effective compared to purchasing a new laser. This path offers the least financial risk, may be the best option for flaps and some of the other corneal applications, and preserves the ability to consider another laser in the future.
As we and other surgeons struggle to make the best decision, it is wise to remember that if you can wait, wait; the outcomes will go up and the prices will go down. A cost-sharing arrangement that spreads out the financial burden and maximizes utilization is ideal when making a major femtosecond laser acquisition.
Look for the best financial deal you can get because it will help you offer the benefits of laser-assisted cataract surgery to your patients at a reasonable price. And, finally, pay close attention not only to publicly reported and published data, but also to anecdotal, first-person accounts from colleagues who have experience with these devices.