Today’s typical cataract surgery candidates are well informed and expect that their ophthalmologist will use the latest technology to perform ophthalmic procedures. Particularly, patients associate laser technology with safety and precision and assume that femtosecond laser assisted cataract surgery (FLACS) is the standard of care for cataract surgery. As such, they’re often quite surprised to learn that not every surgeon utilizes FLACS. Increasingly, patients are coming to us asking for more than basic surgery — they want a better visual outcome.

Laser vs. the Human Hand

Many patients come to my office with some knowledge of FLACS, and many have sought out my practice because I use this technology. Consumers see FLACS as a surgical safety net; they find reassurance in knowing that their surgeon uses the best equipment. Offering femtosecond cataract laser treatment is an essential component for attracting patients — specifically, premium patients. For me, it is important that I offer my patients a full spectrum of services, and, therefore, I work with surgical centers that offer femtosecond lasers.

Although I still perform manual cataract surgery, I believe that femtosecond laser technology offers us the ability to execute a cataract procedure with far greater precision than the human hand. Prior to adopting FLACS, I considered myself a good surgeon and did not think that I needed the laser to achieve great outcomes. After all, I was already obtaining excellent outcomes. However, once I actually started using FLACS, I immediately saw and appreciated the benefits.

In addition to increased safety, when compared with conventional cataract surgery, femtosecond lasers image, automate, and precisely perform several moderately complex maneuvers, resulting in less phacoemulsification exposure, perfect capsulotomy, lens fragmentation, excellent lens centration, and reduced risk of surgically induced endothelial cell damage. Although there is no adequate peer-reviewed conclusion that these factors improve outcomes, I believe that FLACS enhances the safety profile and is an excellent way to consistently ensure correct positioning of premium and toric IOLs.

Stay With the Times … or Be Left Behind

To remain relevant in our field, we must evolve with the times. We live in a social, information-saturated society, so it’s no surprise that our patients have researched their options and discussed or seen online posts about others’ experiences.

Well-informed patients who can afford the technology are willing to invest to achieve their best vision, so they will seek out the practices that offer femtosecond technology. Surgeons who fail to progress will be unlikely to attract this growing patient base.

Likewise, successful ASCs must have state-of-the-art equipment to attract the best surgeons. For instance, I coordinated with an ASC to house a femtosecond laser I wanted to test drive. To get the maximum benefit, I also brought in the ORA intraoperative aberrometry (Alcon). Very quickly, several surgeons began booking procedures in that ASC to access that laser, and the volume of laser surgeries continues to grow there.

Dollars and Sense

I primarily perform FLACS at a corporate-owned ASC facility that purchased the Catalys Precision Laser System (Johnson & Johnson Vision). All parties benefit from this arrangement: patients get the technology and benefits they want; I can offer and use state-of-the-art technology to attract premium patients and offset a declining reimbursement surgery; and the ASC can charge an additional facility/access fee, thereby providing a new revenue stream.

Be sure to consult with an experienced healthcare attorney regarding the calculation of additional facility fees associated with the femtosecond laser. Corcoran Consulting was critical in assisting and advising our attorneys in the legal analysis, as the CMS guidelines and memos specific to FLACS certainly could be more clearly stated.

Cataract surgery is a casualty of declining reimbursement from Medicare and Medicaid; premium services propound a remedy as the number of patients seeking refractive cataract premium procedures grows. When we discuss the laser and its benefits with patients, conversion to the premium product is natural. As we all know, patients who pay out of pocket have very little tolerance for subpar outcomes.

Purchasing a femtosecond laser system is a significant capital expenditure that many surgeons are likely to avoid or are not in a position to make due to space, volume, or financial constraints. ASCs are perfectly positioned to attract surgeons who want to use the technology, but are not ready to make the capital investment themselves. ASCs may consider a variety of professional fee structures, such as per-click fees, flat fees, and so on, to ensure the ASC recovers the cost of the device and maintains profitability.

Will Patients Pay?

I discuss premium procedures with every patient; experience has taught me to never judge whether or not a patient can or is willing to pay for his or her best vision. A significant portion of my patient population is capitated, a patient base that is typically unwilling to pay for any service not covered by their insurance. Surprisingly, we have achieved a 25% to 30% adoption rate in my group simply by educating every patient about the options they qualify for, based on their exam. Most importantly for me is that we don’t employ sales techniques or have any incentives with our staff related to premium procedures. If you have a well-documented patient counseling process that includes specific scripting and is designed to educate the patient, your practice will have a similar experience.

Often, the patients I thought could not afford premium services are the ones who opt for it. Their ability to afford these technologies is enhanced in part due to healthcare financing, such as CareCredit, flexible spending accounts, and healthcare spending accounts. In my practice, the payment mix is 75% credit card, 20% CareCredit, and 5% cash.

Choosing a Femtosecond Laser

Ultimately, features, such as interface, imaging capability, multitasking capabilities, personalization, and ease of integration, should drive the decision. When choosing a laser, it is important to consider the features available and decide which ones are essential to your practice. Based on these factors, I recommended the Catalys for our ASC and have been very happy.

• Interface. The interface on the Catalys is intuitive and easy to use, which makes for simple staff training. Some doctors find the interface so easy and intuitive that they’ll operate it themselves without the assistance of a nurse or technician. The patient interface is gentle with the lowest suction power available. The result is reduced pressure on the eye, which promises a more comfortable experience.
• Imaging. Imaging capability is a preferential feature that can bring tremendous value. The Victus (Bausch + Lomb) is unique in its swept-source OCT technology, which produces high-resolution cross-sectional images for every cut in real time. LenSx (Alcon) offers a view of the entire surgical field in real time, and the Catalys has near real-time visualization and 3D, high-resolution OCT imaging, and integrated guidance technology for increased precision.
• Integration. For surgeons looking for an integrated platform to perform both cataract and corneal procedures, the Victus is currently the only laser that has the ability to switch on the fly between cataract and corneal modes with a wet to dry technique. The Victus is also able to perform LASIK flaps, which can eliminate the need for a separate femtosecond laser for LASIK. Some surgeons also like the attached microscope oculars for better visualization while applying the interface/clip.
• Treatment benefits. Treatment benefits factored strongly in my decision. Multiple centration types, including the scanned capsule and extremely fast capsulotomy of the Catalys, were very important features for me. When treating patients using presbyopia-correcting lenses, the centration of the lens is critical, and the scanned capsule capsulotomy ensures centration on the anatomical center of the lens. This, in turn, best positions the surgeon for centration on the visual axis. Additionally, the Catalys has the highest demonstrated rate of complete 360˚ capsulotomies.¹
• Footprint. Footprint in relation to the available space is also a consideration. Lasers with an attached bed, such as Catalys and Victus, occupy more space than the LenSx, which does not have a bed.
  When considering space and how to maximize efficiency at the ASC, we found that placing the laser outside the operating rooms allows surgeons to go between multiple ORs and the laser. While the doctor is at the laser or in an OR, the staff is able to position patients on the Catalys bed, prepare patients for surgery, and transition them in and out of the ORs. Other centers may prefer situating the laser in the OR.
• Patient comfort. Patient comfort is also part of the bed equation. Victus offers a very sleek and smooth bed that patients find very comfortable. A benefit of LenSx is that it doesn’t have a bed at all, allowing us to roll any gurney right up to it. Although I like the flexibility and decreased downtime during transfers, I personally prefer the stability of an integrated bed.
• Ease of integration. There is always a transition period when adding new equipment. Figure out the flow — see what works for others, plan carefully, and be willing to change, if necessary, to maintain efficient flow and adequate volume. With a little trial and error, we established a flow pattern called “the femto sandwich,” which allows us to have smooth surgical days.
  We begin the day with three to four basic cataract surgeries. During this time, our femtosecond patients fully dilate before their procedure. Alternating FLACS cases with basic cases, femto surgeries make up the middle of the “sandwich.” We conclude the day with basic cases. We originally tried to perform the femto cases first; however, if the patients didn’t fully dilate, we would end up with a backlog. We didn’t want to make the premium patients wait all day, so the middle-of-the-day setup has proven to be a good solution for our center.
  Premium procedures may require 2 to 3 minutes more per case; however, because there is increased revenue from these premium cases, we can afford to schedule fewer patients at a more relaxed pace. With experience, the entire team gains speed and efficiency.

Top-notch Patient Care

At the Virginia Surgery Center, we adopted FLACS early on, and acquired the 13th LenSx (Alcon) laser in the nation. Approximately 40% of our cataract surgeries are laser-assisted, from a standard monofocal IOL with astigmatism correction to all of our advanced technology IOL options. As our femto volume grew, we steadily recognized the growing need for a second laser to accommodate multiple surgeons and to improve efficiencies on days when a higher number of LACS procedures were being performed. Thus, in 2015, we made the decision to acquire a Lensar femtosecond laser. Having two different femtosecond laser systems has been very positive for us. Through experience, I’ve learned that the vast majority of eyes physically “fit” both systems, but the nuances of each system provide different benefits. For example, the Streamline software capabilities of the Lensar imports the patient’s OPD and Cassini topographies, and allows me to treat the topographic astigmatism (or adjust it accordingly), and the IntelliAxis intrastromal tic marks identify the steep meridian of the astigmatism very accurately. I’ve also been very impressed by the lens density detection software, which automatically assesses the lens “grade” from 1 to 4. This provides a very customized lens disassembly pattern for different cataracts. For example, my Grade 1 setting is a single cylinder and cross chop pattern, whereas my Grade 4 cataract pattern allows for smaller 300-micron fragments to effectively soften a very dense nucleus. As femto procedures become more common — perhaps even becoming standard of care one day — I’m grateful to have two excellent laser systems to use in the care of my patients.

— Elizabeth Yeu, MD

Best for Patients

A femtosecond laser is essential equipment for the progressive surgeon who wants to stay relevant and offer the best technology that patients desire. Consider the features you need and want, factor in the footprint, plan OR flow, and analyze the economics to find what works for your individual facility.

The benefits of FLACS for the patient and surgeon may not be readily apparent when comparing final outcomes to manual surgery. However, there is more to the patient experience than just the results. Patients feel safer, intraoperative time is faster and less stressful, and the imaging and level of precision is unmatched by traditional surgery with the human hand.

Most patients will be candidates for FLACS. However, if there is pathology that would prevent any benefit from FLACS, I will inform patients that they’re not candidates for the procedure. Although femtosecond is still in its infancy, where it is going is exciting. The more experience surgeons and patients have with this technology, the more input developers will receive so they can improve upon an already-precise and predictable platform.

FLACS, in the hands of great surgeons, makes us even better. Being able to offer what I truly believe is the most advanced technology in ophthalmology is something I am proud to do, and something I feel good about doing — day in and day out. ■

Reference

1. Day AC, Gartry DS, Maurino V, Allan BD, Stevens JD. Efficacy of anterior capsulotomy creation in femtosecond laser-assisted cataract surgery. J Cataract Refract Surg. 2014;40(12):2031-2034.

Dr. Liang practices in Las Vegas. She is the founder of “Sight for Life,” a nonprofit organization working to assist underprivileged patients suffering from sight-threatening disease to receive medical and surgical eye care. Dr. Liang was selected by the Points of Light Foundation as her employer’s Volunteer of the Year in 2009, and she continues to provide visual restoration to the needy via philanthropic and medical missionary initiatives in the United States and overseas. She is a consultant to Johnson & Johnson Vision and Bausch + Lomb. She can be reached at Eva.Liang@c4slv.com.