Is Now the Time to Add a Femtosecond Laser to Your ASC?

By Karl Stonecipher, MD

Not everyone is ready for a femtosecond laser. It's an evolving technology and many doctors prefer to wait until a new piece of equipment is fully developed and tested before adopting it. Many doctors are viewing the femtosecond laser in the same way they viewed phacoemulsification when it first became available. Given the history in the industry, I think it's safe to say that there won't be an overnight adoption of this technology. But for those of us who prefer to be at the forefront of innovation, we will reap the benefits of more predictable and consistent cataract surgery outcomes.

Paying the Price for Technology

Cost is an issue, so whether the procedure is refractive or cataract, the success of femtosecond surgery — at least for now — will hinge on each patient's willingness to pay out of pocket. You can't charge extra for use of the laser. CMS doesn't allow you extra Medicare charges for the procedure or the device — whether it's a blade, femtosecond laser or phacoemulsification device. However, you can charge for astigmatism correction, premium IOL and toric technology — that's already been established in the marketplace. So, you have to determine if there's a way to implement a premium service mentality in your practice, if you haven't already done so.

About 63% of my cataract patients have three quarters or more of a diopter of cylinder. It's commonly accepted that these patients should have their vision corrected with LASIK or PRK. I believe this provides the highest chance of achieving an optimal outcome — whether it's accommodative or multifocal.

For these same patients, it's in their best interest to have the residual cylinder fixed with LASIK or PRK if you're trying to achieve the best outcome with a premium lens, whether it's accommodative or multifocal.

The need for these corrections may be greatly reduced by the potential benefits of laser cataract surgery, which include:

• allowing for more predictable and accurate placement of the capsulotomy (see Figure 1)
• a more predictable effective lens position
• more symmetric IOL/capsular bag overlap
• reduced reliance on the “surgeon factor” in biometry calculations

Figure 1. This data is from a prospective study to determine the effect of capsulotomy method on Effective Lens Position variability. Using 4.5 mm diameters as the target, LenSx (Alcon) capsulotomy was compared to manual capsulotomy. The authors measured anterior chamber depth and axial lengths using the LenStar Optical Biometry device. The data was presented at the ASCRS 2011 by Dr. Zoltan Nagy who was the lead author for the study.

A Feasible Option

Our patients seem ready to embrace femtosecond technology. I haven't seen a patient yet who has said, “I don't want that” once the technology has been explained. Additionally, as far as patients go, most prefer a laser to a blade when both options are explained to them.

To ensure proper patient education, we offer seminars for our patients to learn more outside their office visit. Discussing all of the technologies in a live seminar in small groups is a great way to teach patients. Patients seem more comfortable asking questions and we can reach many more of them at the same time in this setting.

When they're in the office, patient care coordinators help them navigate the process. And, of course, our doctors speak with patients in the clinic. They've been using iPads to show videos of the premium IOLs offered and our LenSx (Alcon) femtosecond laser technology. It's much more successful than using flip charts. Patients like the video animation. We start with animation, then move to viewing live surgery on video, if the patient desires. Word-of-mouth has already led to patients coming in and requesting this technology.

Like a Good Wine, This Laser Improves Over Time

In our practice, we made the decision that we would completely transition over to femtosecond technology. When I had my first experience with the femtosecond laser in 2002, I felt mechanical microkeratomes didn't offer patients what the femotosecond laser delivered. So, we're telling all patients who choose premium refractive cataract surgery that they should be choosing this technology because we feel it's the best. I've been working with this technology for quite some time, but we've only had the laser in our office since June. Our results are preliminary but so far, we've been extremely pleased with the outcomes.

Our physicians have always been proactive when it comes to adopting new technology. We were actually surprised how quickly our patients chose to adopt the technology. We see that word is traveling fast, which will ultimately increase our bottom line. We also believe it will increase our market share of cataract patients because people are coming in and saying, “I want cataract surgery with a laser.” In accordance with our goal to offer the newest technology, we also use the ORange intraoperative wavefront aberrometer (WaveTec Vision) as part of our premium lens package to deliver tighter outcomes with our patients.

We're looking at the pro forma not solely based on premium IOLs, torics and astigmatic technology, but the bottom line in terms of cataract surgery. We're hoping patients will feel they're getting better results because they're undergoing a cataract procedure along with a refractive procedure that is safer and more predictable. This will be similar to what we saw with our transition from extra-capsular cataract surgery to phacoemulsification cataract surgery and with our transition from mechanical keratomes to femtosecond laser-made flaps with refractive surgery.

With the femtosecond laser, you're adding additional time to your premium process because you need time to create the incision and capsulotomy. Then, laser emulsification of the lens is performed in one room and the patient is moved to another room where we perform the evacuation of the lens and lens implantation. We're performing about four surgeries per hour, but the more our staff gets used to the flow, the faster we've gotten — as is true with any new addition to the operative suite. LenSx has already come up with a faster engine, so to speak, so what used to take 3 minutes, now takes two and with time and technology, this will only improve. This is similar to when I had my LASIK procedure done. When I had LASIK, it was a 90-second flap, now it takes 6 to 12 seconds. As the device improves, the time it takes to perform the procedure decreases.

As with any high-end technology, when LenSx introduced their laser to the marketplace, they didn't want to bring a thousand lasers to the market in one day. From an economic standpoint, they'd love to get that many lasers in the field, but at the same time, LenSx is a very responsible company both in terms of product training, surgical training and making sure that the technology is good when it gets there and it improves once it's out. They want it to be perfectly tuned — like a high-performance sports car. So, you begin with a small number of units and making sure everything is working as expected. As such, there is a waiting list of people who want the technology, just like with the femtosecond lasers of old with refractive surgery. The other femtosecond laser companies, LensAR and Optimedica, are following suit. They have their FDA approvals as well. These lasers will provide elite service and cataract technology that ultimately will lead to a paradigm shift. I think that in 5 years, femtosecond lasers will be used by all physicians and during that time, the technology will continue to evolve. ■

Potential Benefits of Laser Cataract Surgery

• More predictable and accurate placement of capsulotomy • Less deviation in effective lens position • More symmetric 10L/capsular bag overlap • Consistent images from surgeon to surgeon • Reduced reliance on “surgeon factor” in biometry calculations • Procedure softens lenses, which enhances nuclear disassembly and minimizes corneal trauma • Replaces least predictable surgical steps to enhance the surgeon's precision • Can be positioned inside or outside the operating room • Performs four primary incisions: • Capsulotomy • Lens fragmentation • Astigmatic incisions • Cataract incisions

Editor's Note: Dr. Stonecipher says this is preliminary information and data collection is happening as quickly as possible with all platforms.

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Karl Stonecipher, MD, is director of laser and refractive surgery at TLC Laser Eye Center, Greensboro, N.C. Visit his educational Web site at Laserdefinedvision.com.