Answers to Your Biggest Questions

Two surgeons discuss outcomes, procedure volume and efficiency after 17 months using the LenSx Laser.

As surgeons consider whether they should invest in femtosecond laser-assisted cataract surgery, three questions invariably come up. Can the technology improve my procedure? Will enough of my patients choose this option to allow me to at least break even on my investment? In terms of patient flow and awareness, is it logistically possible to succeed? For two surgeons who have been using the Alcon LenSx® Laser for 17 months, the answers are yes, yes and yes. Jonathan M. Frantz, MD, FACS, of Frantz EyeCare and Suncoast Surgery Center in Florida, and Scott LaBorwit, MD, of Select Eye Care in Maryland, recently answered some more detailed questions about their experiences with integrating the LenSx Laser.

Q: Why Did You Decide to Adopt Femtosecond Laser Cataract Surgery?

Dr. Frantz: In my opinion, there's no question the LenSx Laser substantially improves the accuracy and precision of cataract surgery compared to manual procedures. If I program it to create an incision with 20° of arc at 80% of the corneal depth, I know that's what I will get. Removing variability is invaluable for analyzing results, fine-tuning nomograms and improving visual outcomes.

Dr. LaBorwit: The first time I saw the precision of the LenSx Laser in action, I could hardly believe it. Like most surgeons, I thought my capsulotomies were great and my lenssculpting techniques were ideal. Now I know the laser can create my 5-mm circular capsulotomy and place it exactly where I want it every time. I have no doubt that studies will show what a difference femtosecond technology can make for the lens position. With OCT imaging for measuring each eye's distinct size and shape, incisions can be made at specific tissue points, which isn't possible manually. The incisions seal and heal so well that I've reduced my patients' bending/lifting restriction time. The system precisely measures the cataract, too, so the laser can break it up while leaving a cushion at the bottom. In my LenSx Laser cases, I use 50% less ultrasound energy on average, see less corneal edema, and I've seen a reduced need for postop steroids.

My LenSx Laser procedures are more customized, yet more routine. Everything in the OR is more predictable because of the reproducibility of the laser steps. Because of the precision, I can work comfortably with no surprises — even in the toughest situations such as small pupils, long eyes, weak zonules (Fuchs' dystrophy or pseudoexfoliation.) I haven't used iris hooks or manually stretched a pupil in any of my more than 1,000 LenSx Laser cases.

Q: In What Percentage of Your Cataract Surgeries Do You Use the LenSx Laser?

Dr. Frantz: 50%. Patient acceptance of the technology hinges on having thoroughly educated staff members who understand and appreciate its benefits for patients, so they can convey that knowledge and enthusiasm to patients.

Dr. LaBorwit: 65%. We hired a marketing person to help us position the new technology in our market. We added videos about laser-assisted surgery to our website and tried some external advertising, but we've found it's most effective to focus our efforts on our referring doctors and patients who have already decided to come to us. Robert Stutman, OD, MBA, FAAO, our practice administrator, director of optometric services and my partner in the practice, manages our referral network communications. Internally, Dr. Stutman made sure everyone had the opportunity to visit the OR and learn what the LenSx Laser was all about.

Also, I make a video of each patient's laser-assisted procedure and explain each step as I go along. About a week after their surgeries, we ask patients if they'd like to watch it. About 80% opt to do so. We give it to them on a USB drive in the hopes it will help them understand what makes laser surgery different than standard surgery, so they will share what they know with friends and family.

We expect the percentage of cases in which I use the laser to continue to grow, which is why we purchased a second LenSx Laser 6 months ago.

Q: What Impact Has the LenSx Laser Had on Your Efficiency?

Dr. Frantz: At 17 months after our first case, we're as efficient as we were previously. We perform very close to the same number of surgeries in the same amount of time, but because we offer upgraded services for which patients pay out of pocket, we're more efficient from a dollars per hour perspective.

Dr. LaBorwit: For predictable patient flow, Dr. Stutman and I schedule all cataract evaluation visits in full-day or morning blocks. All of the necessary tests are performed, and I spend 15 minutes talking with each patient about their procedure and IOL options. Adding the LenSx Laser to the discussion required about one additional minute. After their talk with me, patients meet with the surgical coordinator. She talks with them further about their options, including costs.

On surgery days, I work out of one OR. The LenSx Laser is in a separate room, and we use what had been extra space as a separate LenSx Laser pre-op area. The OR runs the same as it always has. I essentially created a LenSx Laser "loop." Patients remain on the same wheeled stretcher the entire time. The nurse assesses patients while they're in the LenSx Laser pre-op area. From there, we move them to the LenSx Laser room, out of the LenSx Laser room to the OR pre-op area (where we start IV sedation) and then to the OR. At the beginning of each day, I perform two LenSx Laser sessions in a row. Each one takes approximately 4 minutes. I then alternate between the OR and the LenSx Laser room. I start at 7:30 a.m. and perform 18 LenSx Laser surgeries with phaco by 1 p.m. followed by 5-7 standard procedures. I talk to each patient before docking the LenSx Laser interface, and I talk to each patient and their family member(s) when they are out of the OR. They appreciate hearing directly from me that everything went well.

Q: What's Next for Laser-Assisted Surgery?

Dr. Frantz: The imaging, patient interface, incision software and lens fragmentation components of the LenSx Laser have undergone several upgrades since we purchased the system. Each has delivered measurable improvements in efficiency, flexibility and/or capabilities.

The introduction of the VERION™ Image Guided System is designed to enable us to work with precision and efficiency. The VERION™ Reference Unit (Figure 1) is designed to enhance surgical planning. It integrates with the VERION™ Digital Marker (Figure 2) and the OR microscope to display patient information and images from the Reference Unit and with the LenSx Laser and the CENTURION® Vision System (Alcon's newest phacoemulsification machine) to guide optimal incision and IOL placement. With this type of communication and registration between the various tools we use, we are one step closer to removing any remaining guesswork out of refractive cataract surgery and replacing it with reproducible accuracy. ▪