IntraLase Success in a Smaller Practice
You don't have to be a high-volume LASIK surgeon to use IntraLase.
BY JOHN P. FRANGIE, M.D.

In 2001, I partnered with a well-known national intermediary to open the first fixed-laser center in the Springfield, Mass., area. Given the local economic climate, feedback from potential patients that $2,500 per eye was beyond their reach and the competitive pressures of a weak Canadian dollar that tempted local residents to go north for their surgery, I agreed with the recommendations of my partners to have a relatively low price point.

Cutting a flap with the IntraLase FS laser. PHOTO: COURTESY OF INTRALASE

The strategy worked well initially, as patients were eager to have the new LADARVision (Alcon, Fort Worth, Texas) treatment for a reasonable price, and our surgical days were routinely filled. Then came the final quarter of 2001 — and the refractive bubble burst. Advertising dollars flew out of the window and our costs-per-lead ballooned to $350 per patient. By the end of 2001, our local economy experienced a tightening of discretionary spending for refractive surgery, as patients were confused as to what they were actually getting for their money. Was one tracking laser better than another? How many "most experienced" LASIK surgeons could occupy a 20-square-mile area? How do you reconcile such a wide range of price points? Additionally, there was some patient resistance to the procedure as national media were publicizing patients who had poor LASIK outcomes. Nonetheless, our practice continued to survive, averaging 40 cases per month.

My plan at the American Academy of Ophthalmology (AAO) meeting in 2002 was to upgrade our refractive practice, and this included obtaining information about the IntraLase femtosecond laser (IntraLase, Irvine, Calif.). In this article, I will explain why we eventually made the decision to purchase the IntraLase and how that decision has worked out for our small-market practice.

Initial Skepticism

I was initially impressed with the laser's performance and safety profile, but in my discussions with the IntraLase staff, it was mutually apparent that my practice's business model was not conducive to taking on such an expensive piece of machinery. To put it bluntly, IntraLase had no role in a practice that had positioned itself to compete for the price-sensitive consumer. The femtosecond technology would cost about $400,000 after sales tax, eclipsing the cost of most excimer lasers, and the recommended "upcharge" for this technology ranged from $200 to $300 per eye.

I left the Orlando AAO meeting with a new wavefront unit to attach to my LADARVision, and a bit of skepticism regarding the added value that IntraLase would offer my patients and practice. We had a keratome complication rate of less than 0.6% and an enhancement rate of less than 5%. These rates compared favorably to national averages, and I felt these statistics would improve as I gained more experience and adopted wavefront technology. I did decide that despite our local economy and the national refractive surgery malaise of 2002, it was time to increase our price point. Our practice would be the first in the area to integrate wavefront technology, and this would provide more momentum toward the implementation of a "premium quality" strategy.

The addition of wavefront technology did allow us to raise our price point by an additional 25%, but not everyone fell within wavefront treatment parameters, and it was difficult to explain the benefits of the procedure to patients without tainting the benefits of conventional excimer ablation. The practice milestones in the first half of 2003 were enhanced patient refractive outcomes, in part due to the incorporation of wavefront technology, and a heightened local awareness of our practice as our marketing emphasized improved outcomes through superior technology. This allowed us to increase our profit margin through a higher price point.

We Make the Commitment

While the success of early 2003 was gratifying, it was my impression that our outcomes were still limited by mechanical flap creation — whether it be the induction of variable degrees of higher-order aberrations, variability in flap thickness, "chatter marks" and other stromal bed irregularities or the rare but devastating flap complication.¹ In essence, the creation of a flap with a bladed instrument served as the "limiting reagent" in maximizing our center's patient outcomes.

I then attempted to optimize my outcomes by investigating elimination of the flap by utilizing different advanced surface ablation techniques. Unfortunately, attempts to broadly incorporate advanced surface ablation techniques, including LASEK, gel separation of the epithelium and other surface modalities did not distinguish themselves meaningfully from our standard PRK results, either refractively or in patient acceptance. Accordingly, in the final quarter of 2003, I purchased the third IntraLase system in New England.

IntraLase: Our Learning Curve

The incorporation of a new instrumentation in a practice brings with it a learning curve. In our first 100 cases, there were two cases of flap decentration. Each case was detected prior to the flap being lifted. Accordingly, the patient was asked to return in 3 weeks, and a new flap was created and the cases completed without incident. There have been no decentered flaps over the course of the following 900 cases. There have been no buttonholes, short flaps or free caps in more than 1,000 procedures. Additionally, there has been one case of epithelial downgrowth resulting in a detectable anterior displacement of the flap after 5 weeks. This case was treated by lifting with stromal bed debridement with no deleterious effect on visual acuity, and no evidence of recurrence more than 3 months following the debridement procedure.

Clinically, the addition of IntraLase has given us a higher safety profile as we have had no vision-compromising complications in more than 1,000 cases — both patients with decentration subsequently underwent successful treatment. As late-onset keratectasia has earned a more prominent role in the consideration of LASIK complications, it is reassuring that we commonly have residual stromal beds of greater than 300 mm, even with the higher ablation depths associated with wavefront treatments.^2,3 Our 1-day postoperative Snellen acuities are not significantly different in comparison to our bladed cases. We have had one epithelial defect and four slipped flaps within 1 year (compared to a 3% rate and 1% slippage rate utilizing mechanical microkeratomes). In contrast to the bladed technology, our rate of diffuse lamellar keratitis has gone down to 1% and our incidence of microstriae is less than 3% (we did not keep data on microstriae with the bladed keratome technology, but it is our general consensus that this does represent a significant improvement).

The Staff's Perspective

I did not realize the pressure that my staff felt during our busy "bladed" treatment days. Given enough volume, it is an inevitability that there would be a loss of suction, a patient with tight orbits or a patient who found the lid speculum too intrusive. Those days are gone.

We have been able to place the IntraLase Patient Interface on every patient. There is no speculum and suction breaks are merely inconvenient, not permanently scarring. My staff has new confidence and looks forward to treatment day.

Incorporating the IntraLase femtosecond laser adds an extra step in the treatment of the patient. The 15 kHz laser engine permits flap creation in 56 seconds. As our practice utilizes the LADAR excimer system, this requires a transfer of the patient from one laser bed to another. Typically, femtosecond flap creation in our center requires an extra 5 minutes per patient. The increased time utilization with the IntraLase system amounts to less than half the time that a wavefront treatment adds to a patient's procedure time. As all surgeons know, a superior operative procedure — even if it requires more steps — will ultimately prove to be the most efficient procedure through outcomes improvement. Indeed, our analysis of operating room time utilization shows that the IntraLase system decreases our hourly volume by two eyes on treatment days. However, the improved safety profile actually increases patient throughput postoperatively through more accurate refractive outcomes. Happily, it has been over a year since we have had to "hand-hold" a patient with a flap complication for 6 months, while waiting for the initial suboptimal keratotomy to heal.

The Financial Perspective

The other half of the equation in our decision to purchase the IntraLase was fiscal. Reviewing the literature provided by numerous leading refractive surgeons and seeing the laser in action left no doubt in my mind that IntraLase was a superior technology to anything available for flap creation.

But could a practice with modest numbers in a small market afford this?

We had already increased our fees and added wavefront treatment, and our concerns were as follows:

► patients would not accept the price increase for the new service, and we would have a "white elephant" on our hands

► we would merely be shifting patients' purchasing power from customization to the no-blade technology, essentially nullifying our investment in the wavefront system. In other words, we were concerned that, because of cost factors, many patients would choose IntraLase and opt not to have wavefront

► the refractive market would take another swoon, leaving us with a highly capitalized, but underutilized system.

Meanwhile, our practice goals for the acquisition were as follows:

► continue to offer the highest quality refractive procedure and maintain our practice's brand as the refractive leader in our market

► to gain market share not by shifting patients from other practices, but to actually expand our local market by generating new leads through patients now willing to consider a refractive procedure because of the advantages offered by this technology.

Our Fiscal Strategy

Prior to purchasing the IntraLase system, our refractive price points were $1,495 per eye, with a $375 per eye upcharge for wavefront-guided treatment.

We then decided to make IntraLase available as an adjunct to either treatment for an additional $500 per eye. When we first offered refractive surgery, the procedure was designed and priced to deliver volume. Accordingly, the initial price was targeted to be below national averages in an attempt to compete for price-sensitive patients in a market where deep discounting was available from either national chains or from Canadian practices. This was moderately effective until the refractive market softened in late 2001.

We then decided to use early 2002 as our benchmark, and assume that the practice would not see a volume increase as a result of adding IntraLase. Given that scenario, we asked our accountant to calculate a price point to incorporate the IntraLase technology, assuming that 70% of our cases would be done with the new system. Additionally, I wanted the cost of the laser to be amortized within 3 years and we did not want to alter the profit margin per eye. Using those parameters, we arrived at a charge of $500 additional per eye for IntraLase.

My Accountant's Perspective

Our practice has seen a year-to-date increase in volume of 20%. I attribute half of this as reflecting a generally favorable increase in the procedures performed nationally. What has been truly surprising is that within 2 months of offering this technology, 80% of our patients were electing to have the procedure and we now perform IntraLase on more than 90% of our patients. When I speak about the patient acceptance of this technology, I purposely avoid the use of the term "convert." Today, it is the rare presenting patient who does not request the IntraLase procedure, as more than 90% of our patients actively seek the femtosecond technology. Interestingly, this favorable acceptance of IntraLase has not impacted the rate of wavefront treatment in our practice, as our patients understand that the two technologies complement one another.

While our initial goal was to maximize patient safety and outcomes, our first year with the femtosecond technology resulted in a 30% increase in revenues, which translated into the center increasing its profitability by 43%. Truly, we are reaping the benefits of sharing a win-win situation with our patients.

Advice to Smaller Practices

The addition of the IntraLase femtosecond system is a feasible undertaking for a small-market practice that averages 40 to 50 cases per month. While this technology improves outcomes and safety profiles, it may not be conducive to practices with overhead constraints whose business plan is targeted toward the cost-conscious consumer. Certainly, incorporating this technology required a change of the practice business plan from providing quality surgery at a "value price" to a quality-conscious practice set upon maximizing individual outcomes. Expectations on a clinical and fiscal level continue to be met as the superior refractive and safety profile of this technology is well accepted by staff and is valued by patients.

John P. Frangie, M.D., is the medical director of Pioneer Valley Ophthalmic Consultants, based in West Springfield, Mass., and assistant professor of ophthalmology at Boston University School of Medicine.

He can be reached via e-mail at jfrangie@frangieeye.com.

REFERENCES

1. Hamill MB, Kohnen T. Scanning electron microscopic evaluation of the surface characteristics of 4 microkeratome systems in human corneas. J Cataract Refract Surg. 2003; 28:328-336.

2. Seiler T, Koufala K, Richter G. Iatrogenic keratectasia after laser in situkeratomileusis.J Refract Surg. 1998;14:312-317.

3. Pallikaris IG, Kymionis GD, Astryakakis NI. Corneal ectasia induced by laser in situ keratomileusis. J Cataract Refract Surg. 2001; 27:1796-1802.