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Shared access may be ideal model for surgeons to gain experience with femto cataract surgery
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There is no way to write a commentary on femtosecond laser-assisted cataract surgery, or FLACS, without alienating many, including close friends and colleagues in practice and industry whom I work with on a daily basis. Unfortunately, that is the task at hand, and as Chief Medical Editor of one of the most widely read publications in ophthalmology, I cannot duck the responsibility.
Working together with Sightpath Medical, I acquired one of the first 10 LenSx lasers (Alcon) about 2 years ago. None of my partners at Minnesota Eye Consultants were interested enough in this technology to invest, so I paid 50% of the cost myself and Sightpath paid the other half. I was, of course, fascinated to learn more about this instrument that carried the promise of changing forever the way we perform cataract surgery in advanced countries and saw it as an innovation that might match the transition to phacoemulsification and posterior chamber lenses.
I was also highly motivated to work with Sightpath to deliver an access model using mobile technology that would make this laser technology available to every ophthalmologist in the U.S. at a reasonable cost. We spent about a year with me operating at my ASC with the LenSx laser on a Monday, loading it on a truck and driving around the Midwest in all seasons, from 100° summer days to –20° winter days, and bringing it back to my OR for the following Monday’s surgery.
We learned we could safely mobilize this technology and, with a well-trained technician, serve at least three separate locations a week with no sacrifice in quality of care vs. a fixed-site instrument. In fact, the presence of a highly experienced surgical technician who was also trained to calibrate and troubleshoot the instrument proved to be such a valuable asset that one could argue outcomes were enhanced compared with the occasional user in a fixed site.
After a year, Sightpath purchased my 50% ownership in MoFe #1, as it was called, and now is moving 30 such mobile shared-access LenSx femtosecond lasers around the continental U.S. on a daily basis. As an aside, I serve as a medical consultant to Sightpath and have for more than 20 years as it developed mobile standard cataract offerings for rural communities and mobile Visx excimer and IntraLase femtosecond lasers (both Abbott Medical Optics) for corneal refractive surgery. It has now supported more than 2 million surgical procedures with its mobile surgery equipment offerings and is an option all surgeons should know about. Of course, there are other high-quality companies with mobile cataract equipment, including femtosecond lasers for LASIK and FLACS, but to date, my direct experience has only been with Sightpath.
The biggest challenge for most surgeons to incorporate FLACS in their practice remains the cost of access, and mobile shared access remains a good option for many. In addition, shared access at open-panel ASCs and hospitals, where many surgeons can use a laser, is another attractive option. In my city, both Phillips Eye Institute and Fairview University Hospital are in the process of creating a shared-access fixed-site model for FLACS at reasonable costs. Of course, those of us who can bear the cost and own an ASC prefer to own our own equipment, but some kind of shared-access model in my opinion remains an attractive way to gain experience with FLACS and see how it works in one’s practice before purchasing the technology.
In my opinion, the surgical volumes required to support a laser are at a minimum 400 eyes per year, and economies of scale favor centers that can approach 1,000 eyes per year. This is the exact same number of cases that we learned were necessary to support excimer and femtosecond lasers for a corneal refractive surgery practice, which makes sense because the technology costs and reimbursements are similar.
The good news: FLACS is becoming available to all surgeons in the U.S. through one access model or another. Trained surgeons and case volumes are growing at a healthy rate worldwide, which is expanding learnings exponentially.
In the next issue, I will discuss my personal experience with FLACS and how I project its role will evolve over the next decade. That commentary will likely be even more controversial, so I am glad I have a couple more weeks to prepare before putting it in print.