Viewpoint

Putting a Price on Progress

FROM THE CHIEF MEDICAL EDITOR
Larry E. Patterson, MD

Unless you've been hiding under a rock somewhere for the last few months, you've already heard and read a great deal about the newest revolution in cataract surgery: femtosecond lasers. The pages of this journal and others have discussed the amazing potential benefits of this evolving technology.

In case you have been hiding under a rock, the scenario goes like this: when your cataract patient is ready for surgery, he will initially go under the laser for the femto "pretreatment." The laser first goes deep into the core of the cataract, subdividing the denser nucleus into small cubes that look like something out of an ice maker. Next the laser moves anteriorly, cutting the perfect capsulorhexis you previously only dreamed about. Finally, the laser creates both your main and side-port incisions — and if you're in the mood, it can also make limbal relaxing incisions of the perfect depth and length. Now it's time for you to enter the eye. The incisions are easily opened with a blunt instrument and the anterior capsule is grasped with forceps and removed from the eye. Because of the nuclear pretreatment, much less ultrasonic energy is needed to aspirate the cataract.

The upsides? You have clearer corneas because the phaco power and time were reduced, maybe even avoiding further corneal surgery in the case of significant Fuchs' dystrophy. The implant is more perfectly seated and "shrinkwrapped" because your now-perfect capsular edges nicely overlap your IOL by 0.5 mm for 360 degrees. And you possibly have even fewer cases of endophthalmitis because of your precisely constructed wound.

The downsides? With every new technology there are always a few. This new laser really is a game-changer for cataract surgery. While all the approvals have yet to take place, and we don't know all the details, one thing seems crystal clear: this wonderful new technology will cost somebody a lot more money.

"But," you argue, "it's just like premium lenses." If people want them, they can just pay out of pocket. Same thing with the femto treatment.

Wrong. It's not like premium lenses. I offer premium lenses to all my patients who are candidates. The overwhelming majority decline, mostly due to cost concerns. In fact, most decline even the small fee for an LRI. But all these patients, premium IOL or not, get the same quality in both surgical procedure and outcome. Yes, premium IOL patients are more likely to function without glasses, but the quality of all my surgeries is equal.

But with the femto-assist, the quality will actually be better! Less trauma to corneas, less chance of decentered IOLs, and less endophthalmitis risk. I'm very excited about this new breakthrough, but I'm not quite sure how we position it yet. I don't want to put my patients in the position of having to decline a superior procedure because of financial concerns, and yet I can't see how I can add another piece of equipment without some cost sharing.

Which reminds me: while you inventive geniuses are at it, would it really be so difficult to make one single femtosecond laser device that does LASIK flaps as well as the cataract stuff? Now that would be progress!

Editor's note: For more thoughts on this topic, see "As I See It" by Paul Koch.