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Femtosecond laser-assisted cataract surgery gaining acceptance in the UK
Evaluation for cost-effectiveness and National Health Service funding may not be so distant in the future, according to one surgeon.
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As femtosecond laser-assisted cataract surgery rapidly takes off in private practices in the U.K., reimbursement by insurance and, eventually, the National Health Service might not be such a distant-future goal.
“If we can demonstrate that complications are lower, outcomes are better and that we can perform high-volumes surgery, there will be good arguments to have femtosecond laser cataract surgery evaluated for cost-effectiveness and National Health Service (NHS) funding,” Sheraz M. Daya, MD, medical director of the Centre for Sight, East Grinstead, U.K., said.
The new femtosecond laser technology for cataract surgery has been adopted by several private practices and by Moorfields Eye Hospital in London to treat private patients.
“We are working hard at promoting what we believe should soon become the new gold standard of cataract surgery. We mainly do it through educational initiatives aimed at ophthalmologists, optometrists and NHS officials,” Daya said.
Sheraz M. Daya
The policy adopted by the Centre for Sight is currently to offer femtosecond laser-assisted cataract surgery at the same price as conventional phacoemulsification.
“It is the only way that economically and ethically makes sense to me,” Daya said. “In this way we can offer it to everyone. It would be hardly justifiable within our system to have a technique that we say is better and perform this in some patients and not in others. Most practices charge more for femto, but since there is no accurate modeling or historical conversion rate, it is difficult to establish how much the extra charge should be; prices are extremely variable.”
New government provisions in the U.K. have introduced the possibility of private practices providing services under NHS coverage. Only specific procedures would be reimbursed; however, this “hybrid” model combining private and NHS care could be the driving force in fostering innovation within the NHS by showing the advantages, affordability, productivity and cost-effectiveness of innovative treatments and technologies.
“We have started treating some NHS patients with the femtosecond laser on a trial basis to test out the commercial modeling. We shall have to see if it makes financial sense and what numbers are required to compensate for the extra costs,” Daya said.
At the Gemini Eye Clinic, Czech Republic, Pavel Stodulka, MD, PhD, introduced the model of housing the femtosecond laser in a separate room, feeding two ORs, which demonstrated that the procedure can be carried out cost-efficiently. Daya himself showed in a recent live surgery session that four procedures can be performed in little more than 1 hour with the laser and operating bed in the same room.
“This is the standard of what you can do, three to four cases per hour. It dispels some of the myths about taking more time,” he said.
A versatile laser platform
Daya uses the Victus laser platform (Bausch + Lomb Technolas). It is the platform that makes the most sense in an anterior segment practice, because it is an anterior segment workstation, he said
“I can do refractive surgery, corneal transplant and also cataract surgery with it. It’s a versatile, reliable laser. Not a perfect technology for doing everything yet, but it is evolving and it’s great for cataract,” Daya said.
One feature he finds particularly attractive is the online optical coherence tomography, which detects changes that might occur while docking the patient or during laser treatment.
“You don’t know what’s happening with some of the other lasers. With the Victus, you see it and you decide whether you want to continue or not. We as surgeons like to know what we are doing while we are operating,” Daya said.
Over 1.5 years, Daya has performed about 800 procedures. In a study, he compared ultrasound time between standard phaco and his first 108 Victus cases. Significant reduction in all phaco parameters was observed.
New technique
Daya developed a new technique of trans-lenticular hydrodissection with a cannula developed by Bausch + Lomb that helps reduce phaco time even further.
“I put the cannula through one of the incisions in the nucleus and inject fluid, which goes around to the back of the lens with a fluid wave, hydrodissecting the lens. I discovered by mistake this new possibility of using fluid to break up the lens,” Daya said. “I was trying to break it up with the cannula, by mistake I injected [balanced salt solution], I saw a fluid wave and the lens became mobile.”
While his average phaco time used to be 0.99 seconds, it is now further reduced to a mean of 0.4 seconds.
“This is what’s really exciting about femtosecond cataract surgery: It’s all very new. We are using our reference points of regular cataract surgery to do this surgery, and as soon as we start pushing the frontiers, we shall probably realize there are different ways of removing the lens. There may be ways we have not even thought about yet,” he said.
Additionally, IOL design will change considerably in relation to the better capsulorrhexis, and new solutions for accommodation might arise, Daya said. – by Michela Cimberle