Mature vs. Emerging Technology: An Insider's Perspective
An inventor and clinical investigator weighs in on the mechanical microkeratome and the laser keratome.

Editor's note: Lee T. Nordan, M.D., helped develop the Amadeus microkeratome and performed the first several hundred IntraLase femtosecond (FS) laser procedures in the United States. He continued to use both the Amadeus microkeratome and the IntraLase FS laser until his retirement from eye surgery. Here's his unique perspective.

In My Experience

There's no question that a surgeon can create an excellent flap with either the Amadeus microkeratome or the IntraLase FS laser. The surgical results with either modality can be excellent. If pressed, I'd have to say there's no distinguishable difference in flap quality with either technology. In my experience, both consistency and depth of cut were excellent.

Ergonomics and efficiency weren't issues in my practice either. I used the VISX excimer laser and had the bed positioned between the VISX laser to the right and the IntraLase laser to the left. I'd swivel the bed to the microscope on the VISX and then swivel it toward the Intralase, as needed.

Whether I used the Amadeus or the IntraLase, I used the same staff of two -- a scrub nurse, who was responsible for the Amadeus microkeratome and a surgical technician who greeted the patient in the operating room and programmed the VISX and the IntraLase computer.

What should you consider when deciding which technology to use? In my opinion, the issue becomes safety vs. cost.

A Word About Safety

The IntraLase offers a relative advantage of being able to re-do an aborted flap attempt within a few minutes, rather than having to wait at least several months. With a microkeratome, the surgeon makes a side cut along with the flap dissection, so there's always at least a partial flap during all stages of the keratectomy. If there's a problem with a microkeratome keratectomy, the flap should heal for 3 months before another keratectomy can be performed.

If a surgeon has an unacceptably high complication rate with a microkeratome (two complications per 100 is unacceptable, in my opinion), then he has two choices: Either get an Amadeus microkeratome or get an IntraLase. Cost will probably be a factor in that decision.

Cost Concerns

Two types of surgeons will buy an IntraLase: The surgeon who's having problems with a microkeratome and wants to improve surgical outcomes and the surgeon who's getting great LASIK results with a microkeratome but who wants the IntraLase for practice development. Regardless of motivation, a surgeon must consider upfront and long-term costs as well as the competitive environment.

When I was using the IntraLase, it cost about $250,000, and the company charged a per-case user fee of about $150. (New financial programs may have been developed recently.) Compared to a new microkeratome that costs about $60,000 and $60 per blade, that's a significant investment. What's more, every surgeon who has an IntraLase does significant external marketing. Is it worth the money? It depends upon the effectiveness of the marketing and the financial bottom line.

About 100 surgeons in the United States now use the IntraLase. Although future competition among IntraLase users in the same cities might decrease the number of patients per surgeon, the concept of creating a LASIK flap with a new laser technology may attract more interested patients. It will be interesting to see how the dynamics of this balance plays out.

Temper Your Decision

Whether you decide to change to the Amadeus microkeratome or add an IntraLase FS laser to your practice, be sure to temper your decision with knowledge. The experiences of the surgeons reporting in this supplement will add further insight.