Transitioning to New Technology
Doctors discuss their successful experiences switching surgical systems.
BY JOHN PARKINSON, ASSOCIATE EDITOR

Should I upgrade my system? Would a new system create a substantial learning curve? Is what I have now in my practice adequately serving my patients?

These types of questions evoke pro and con responses, making the choice to upgrade even more difficult. Combine these with equipment upgrade costs and conflicting product literature about systems, and all these factors may make surgeons reluctant to buy anything.

Although questions come up whenever the subject of buying new equipment arises, this internal debate is yielding success for some surgeons who made the decision to switch and who are now thriving after transitioning to newer systems. In this article, cataract and refractive surgeons will discuss their experiences in adapting to new surgical systems and provide insights into what influences them to make purchasing decisions.

An Early Adopter

Roy Rubinfeld, M.D., of Chevy Chase, Md., tends to integrate new technology before many others are ready to do so, and is willing to put in the time necessary to evaluate a new technology's potential flaws. He is an early adopter of developing LASIK surgical systems, and says he has owned approximately10 excimer lasers in the last 10 years.

Although Dr. Rubinfeld is a careful early adopter by nature, and he had heard from several colleagues outside the United States that they were achieving positive results with the Allegretto Wave (WaveLight Technologie AG, Erlangen, Germany), at the time he believed the key to better custom refractive outcomes was wavefront-guided lasers. Nevertheless, he maintained his interest in the Allegretto Wave and eventually became an advocate for the system. Dr. Rubinfeld spends a good portion of his surgical time at three TLC Centers, and he felt TLC should provide the technology. When the company purchased the system, Dr. Rubinfeld began to use the WaveLight laser on patients who could not be operated on with a wavefront-guided machine. Gradually, based on low enhancement rates and experience, he changed his criteria for choosing the Allegretto Wave.

"Over time, I started to expand the type of patient that I would perform on the Allegretto Wave, to the point I am using it 85% to 90% of the time," explains Dr. Rubinfeld.

For the remaining 10% to 15% of his patients, he uses a wavefront-guided laser. He uses it for patients who have night vision problems, irregular astigmatism and some problem patients who have undergone LASIK at other practices and come to his practice seeking retreatment.

Dr. Rubinfeld says new systems' ergonomics are not usually discussed when a surgeon is seeking to purchase a new machine but this is an important consideration. He says the WaveLight laser's slit lamp illumination, table height and laser speed were all factors requiring a brief, easy adjustment. He compares adjusting to a new surgical system to the experience of test driving a new car in some ways — one must acclimate to the individual characteristics of the machinery.

Dr. Rubinfeld's learning curve with the Allegretto Wave laser went smoothly and he credits Allegretto's nomogram with part of the successful transition.

"I found it to be a remarkably easy transition. In using this nomogram, I've achieved a less than 2% enhancement rate," says Dr. Rubinfeld. "I must say not having to do wavescans, WAMRs (wavefront adjusted manifest refractions) and other position-adjusted calculations has been a real pleasure."

Overcoming the Challenging Case First

John Millin, M.D., began to think seriously about a system upgrade after the hospital he worked for in Cheyenne, Wyo., decided to open an ASC. While in talks with the hospital to transfer himself to the ASC, he also began discussions with the hospital's administration about the type of phacoemulsification machine he wanted for the surgical center.

Dr. Millin notes the hospital's existing phaco machine was approximately 6 years old, and he says the system's age, coupled with his desire to perform "cold phaco," influenced him to pursue an upgrade.

After getting Dr. Millin's input on the subject, the hospital decided to invest in the Sovereign Compact system (Advanced Medical Optics [AMO], Santa Ana, Calif.). In determining which phaco machine to choose, Dr. Millin credits not only AMO's product but also the manufacturer's support.

On the first day Dr. Millin was scheduled to use the Compact, he had his procedures set up based on the degree of difficulty. This way, he could start with simple, straightforward cases in the early morning and progress through the day until he had the hardest case as his last procedure.

Unbeknownst to him, a scheduling change made his most difficult case — a 4+ sclerotic lens — the first procedure of the day. A dense brunescent cataract has its built-in challenges even when working with a familiar phaco machine, but Dr. Millin found himself with a new system and no previous experience with it. Fortunately, the procedure went smoothly.

"The machine [Compact] functioned the way it was supposed to. There was total anterior chamber stability as I was moving through the lens," explains Dr. Millin.

He was also impressed by the ability to acclimate so easily to the Compact that day. "That's what amazed me; there really was no learning curve."

Outside Influences and Motivating Forces

Dr. Millin says ophthalmic surgeons must be able to upgrade systems when new technology becomes available. With vendors continuously developing new products, physicians say they want to keep up to date with these emerging technologies, so they attend peer-related, vendor-sponsored meetings.

"Most of the practical information on new technologies you get is from going to meetings," acknowledges Dr. Millin. He also says the product presentations motivate him to try out new technologies.

James Kelly, M.D., concurs about the importance of professional meetings, and he regularly attends those of the American Society of Cataract and Refractive Surgery (ASCRS) and American Academy of Ophthalmology (AAO). "I go to the ASCRS and AAO meetings every year. There are fairly intensive refractive surgery discussions during those meetings, and I would say I get the vast bulk of my information [from them]."

In addition to meetings, literature about products and procedures is made available to the public via the Web and through various advertising venues. As this information is disseminated to the public, potential patients are made aware of the latest FDA approvals and what services practices in their area are offering.

Because of this, physicians like Dr. Kelly have savvy patients who inquire about the latest procedures and newest technology.

"There's always that business issue of, 'are you being competitive in your marketplace?' You always have that pressure from yourself, and also from your patients," says Dr. Kelly. "You'll have patients come in and say, 'I understand that Dr. Smith down the block is doing wavefront, are you doing that also?' I feel that pressure to say, 'I'm using the latest approved technology.'"

Dr. Kelly practices in Manhattan and Long Island and these environments lend themselves to a greater concentration of competition.

Conversely, being in a smaller market with fewer people and less competition, Dr. Millin does not have the same market forces motivating him to upgrade. "You don't have the pressure of the guy across town saying he has a newer, better, safer machine."

A New Practice, A New System

There are situations where the surgeon does not influence the switch, but rather a change in environment dictates the transition. Robert Marquis, M.D., went from performing cataract surgery using one major manufacturer's cataract surgical system to the Millennium System (Bausch & Lomb, Rochester, N.Y.) During his residency and fellowship training, he worked on and became comfortable with the first system. Dr. Marquis made the transition to the Millennium because the surgeons at the Austin, Texas practice he was hired to work for performed cataract surgery with B&L systems.

Dr. Marquis had been used to working with a peristaltic pump initially, and at the time Dr. Marquis started working for the practice, the Millennium utilized a venturi pump only. So naturally, he had some reservations and concerns transitioning to a system with a different pump.

"I was very cautious because I had heard about the different characteristics of the [venturi] pump. The rate [of speed] the vacuum builds up is very different with the peristaltic as opposed to venturi," says Dr. Marquis. He says the peristaltic pump speed seems to rises faster than the venturi.

While Dr. Marquis was getting acclimated to the Millennium, B&L developed its advanced flow system (AFS) with peristaltic technology. B&L provided him with the AFS, and he reports recent success with the technology.

The addition of the advanced flow system provides surgeons with the option of peristaltic or venturi capabilities on the Millennium system.

Science-Guided Decision

The ability to provide good refractive outcomes consistently is very important to surgeons, and securing the latest technology can offer superior results and give doctors the ability to tell patients they are getting the most contemporary treatments available. While Dr. Kelly says he was achieving good refractive results with his older excimer laser, part of his rationale for buying a new wavefront-guided refractive surgery system was the science behind the technology.

"When I looked at the science behind the wavefront technology, it made more sense to me to register the wavefront to the cornea," explains Dr. Kelly. At that time, Dr. Kelly says the only system with such capability was the LADARVision System (Alcon, Fort Worth, Texas).

As the principal of two practices, he bought two systems so he could have one for each office. Initially, his concerns going into the transition were patient outcomes and the possibility of over or undercorrecting patients' vision, without a personally established nomogram for the LADARVision System. Dr. Kelly credits Alcon for its support in providing references for developing a nomogram.

"I spoke to colleagues who were using the system, and gathered data as to what they were doing." By discussing potential refractive error scenarios with other doctors, Dr. Kelly gathered information and created a nomogram.

He was successful with his first 10 cases using this nomogram. With his next 20 cases, he had some minor undercorrections. However, the nomogram helped create a foundation says Dr. Kelly.

Today, Dr. Kelly is performing about 98% of his refractive cases with the LADARVision. He uses his older laser for the remaining 2% of his patients who have abnormally small pupils that despite dilation tactics, cannot become fully dilated.

Getting out of the Comfort Zone

Adapting to a new system can seem like a difficult task, especially considering the invasive nature of eye surgery. Surgeons, just like everyone else, like familiarity. With the possibility of complications in every surgery, knowledge of how a system performs can be key in making a surgeon feel comfortable going into a procedure. With support from peers and the vendors, the learning curve can be minimal according to the surgeons interviewed for the story, and transitioning to a new cataract or refractive system can prove to be a rewarding experience.

Dr. Millin says ophthalmic surgeons must be able to upgrade systems when new technology becomes available.