Custom Ablation: Ready or Not, Here It Comes
Should you be among the first to offer it? Should you be among the first to offer it?
By Ophthalmology Management Staff

Now that the FDA's Ophthalmic Devices Panel has recommended approval of Alcon's custom ablation platform, it should only be a matter of months before full approval and the availability of the new technology to all. That means it's time for refractive surgeons to make some business decisions, observed Dan Durrie, M.D., during a conversation with Ophthalmology Management.

The pre-op higher-order aberration RMS is only 0.07 microns here, which makes this patient a good candidate for traditional LASIK. (Images courtesy of Dan Durrie, M.D.)

"I think by now, most ophthalmologists know where they fit on the technology curve," he said. "If your practice is oriented toward innovation and new technology, then custom ablation will be for you. If you've traditionally stayed at the top end of the market by investing in new technology, your patients will expect you to be in right off the bat."

One of the first decisions you'll have to make, Dr. Durrie said, is whether to switch lasers if you're not already using Alcon's LADARVision. "Also, you should be determining who in your patient base is a good candidate for a custom ablation and who can have a traditional treatment," he said. (See images below.) "For quite some time, in addition to the eye-health exam, I've been performing what I call an "advanced vision analysis" on all of my patients who are interested in refractive surgery. I combine information from the Orbscan and aberrometry to determine whether a symmetrical treatment will fit well on a certain eye, or whether it would leave the patient with residual higher-order aberrations that would degrade the quality of his vision enough that he should wait for a custom ablation.

"The studies that have been reported to date have shown that if patients don't have significant higher-order aberrations pre-op, they don't benefit from custom ablation. So far I've advised about 10% of the people I'm screening to wait because the new technology looks as if it might be a better treatment for them. About 90% of the people I'm seeing now don't have any significant higher-order aberrations, so it's fine to treat them with a conventional laser."

Costs and fees

Now is also the time to look at costs and fees, Dr. Durrie said. "It will cost more to perform custom ablations," he said. "I don't think this is something that's going to be in the plan of the discount laser centers early on. You have to consider the cost of the equipment or the upgrade, plus the time it will take to educate yourself, your staff and your referral doctors. The bottom line will be whether differentiating your practice will be enough of a competitive advantage to justify the costs.

"An important part of your cost structure will of course be your fees," he continued. "We should be setting our fees for custom ablation logically, based on our costs. We don't want to overcharge, but at the same time, this is a chance to look at how we're doing overall and look at this as a business model. We know now that charging low fees to increase volume doesn't work."

"Custom upgrades"

Dr. Durrie believes that the most common use of custom ablation in its first few years on the market will be an off-label use -- what he calls "custom upgrades." By that he means improving the vision of patients who've already undergone LASIK but have some quality of vision problems caused by pre-existing higher-order aberrations that weren't corrected, or surgically induced aberrations.

"These aren't 'enhancements' in my nomenclature," he said, "because we're not using the same technology again to get closer to the target. We're using a new technology. So, surgeons will need to determine whether custom upgrades could be an important addition to their practices for the long-term."

Whether custom ablation becomes the standard will depend on the quality of the results, Dr. Durrie said. "If people get better vision, then certainly it will. We'll have to work with it for a little while to learn that."

Patients could very likely push the market in that direction, he said. "The studies done by both Alcon and Bausch & Lomb show that people do get higher quality night vision with custom ablation. That alone, I think, will be worth the extra cost to them."