Viewpoint

Just the FLACS, ma'am

Larry E. Patterson, MD
From The Chief Medical Editor

At the Orlando AAO meeting, femtosecond cataract surgery was front and center. One system is now approved, and three or four others may be approved next year, so I'll revisit this subject with a few observations.

1. I'd like to propose a new acronym. After all, ophthalmologists are lords and masters of the medical acronym. So I suggest “FLACS” — for femtosecond laser-assisted cataract surgery. Remember, you heard it here first. (Seriously, did you think LASIK sounded cool the first time you heard it? No, you thought it sounded like a diuretic.) FLACS is more accurate than the current favorite term, femto-phaco, which doesn't ring true to lovers of precision like us.
2. FLACS is really, really cool. In the exhibit hall, I successfully cut a lovely pattern into a small hemisphere of plastic. It's now a souvenir on my desk.
3. Each day that I'm operating and doing a difficult capsulorhexis or experiencing difficulty chopping a nucleus, I dream of having a laser do it for me.
4. Someday, maybe five or 10 years in the future, we will likely be using FLACS to some extent on many if not all of our cataract surgery patients.
5. FLACS may give us better outcomes. I say “may” because it's so new that there's not a lot of independent data showing how much, if any, this technology will affect outcomes. I'm hopeful and optimistic that it'll produce better results.
6. FLACS is not quite ready for mainstream adoption. I talked with more than one doctor at the AAO meeting who'd personally seen complications from the procedure, including dropped nuclei, less than perfect capsulotomies, and even an abysmally decentered LRI. As with all new technologies, issues that crop up in the early days tend to improve over time.
7. There is no good financial model in 2011 for FLACS. Will there be one in 2012? That's what we're all asking.

That last point is the real acid test, of course. Informed leaders at the meeting expressed reservations about our ability to legally charge patients for FLACS, even in the context of a premium implant procedure, because Medicare already covers the steps that the laser performs. This must be clarified or even changed by CMS. Still, the average cataract surgeon uses premium implants in only a small percent of patients. Even if your patients were willing and/or able to pay extra, you might have to do about 500 to 1000 FLACS per year just to break even, according to one analysis I saw at the AAO. Not to mention that it adds considerable time to the procedure. To put it more positively, if industry can work out a viable financial and workflow model for us, they'll have thousands of eager new customers. Until then, we're struggling to crunch the numbers.

Extracap was a huge improvement over intracap. Phaco was a big step forward from extracap. FLACS may be a bit better than the great operation we currently have, but at much higher cost. Is it possible we could be doubling or tripling our cost of cataract surgery for small improvement in outcomes? If you want to be an early adopter, go for it. Just be clear on the risks and uncertainty that come with that. Don't jump in and FLACS it up prematurely!