EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/276058
E W FEATURE 118 by Ellen Stodola EyeWorld Staff Writer Ethical dilemmas with femtosecond cataract surgery Femtosecond technology presents some ethical hurdles for surgeons T he femtosecond laser is a new technology that many are seeing the benefit of in- corporating into surgeries; however, there are still is- sues to be ironed out with the tech- nology, including the cost and the surgery time. Not all doctors have this technology readily available to patients, and in terms of cost, the extra fees for the femtosecond laser are specifically addressed under CMS guidelines, with the ability to charge only in certain circumstances. John Banja, PhD, Emory University Center for Ethics, Atlanta; Richard Hoffman, MD, clinical as- sociate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Eugene, Ore.; and Kevin M. Miller, MD, Kolokotrones professor of clinical ophthalmology, Jules Stein Eye Institute, Los Angeles, spoke about the ethical issues surrounding femtosecond cataract surgery. Presenting femtosecond cataract surgery to patients Despite not having a femtosecond laser where he works, Dr. Miller thinks the presentation of the technology is fairly simple. "If it's a cataract patient, you have to be doing a non-covered service to bill for the laser," he said. The only non- covered service that makes sense is the astigmatism service. He said that using a femtosec- ond laser for astigmatism manage- ment is a safe harbor for use of this technology, adding that another par- tially safe place is offering the tech- nology when performing imaging as a necessary preparation for implan- tation of a premium lens. The latter, while approved by CMS, doesn't make much sense, thinks Dr. Miller, because the imaging is performed for the sole purpose of facilitating non-covered services such as the incisions, capsulorhexis, and lens softening. "You're only safe if you're offer- ing astigmatism management as part of your non-covered package," Dr. Miller said. "A premium IOL could be in that package, but you can't price the premium IOL higher just because you want to use a femtosec- ond laser to make the incisions." Dr. Banja said femtosecond technology should be presented to a patient only if his or her condition warrants it. Thus, using femto to "correct for astigmatism" in a patient who had only traces of it would hardly be ethically accept- able, not to mention the risk of that being discovered in an audit. Dr. Hoffman said that he cur- rently does not offer femtosecond laser cataract surgery to his patients. However, he would explain the situation to a patient if he or she were interested in the technology. "I would explain that at this time, insurance and Medicare do not cover the laser treatment and due to Medicare regulations, we could not offer it unless they had astigmatism that would be treated at the same time," he said. "I do not believe that it offers significant enough advan- tages that there are any ethical concerns about not performing the surgery with the laser if a patient cannot afford it." When patients could benefit but don't qualify for a femtosecond procedure Dr. Hoffman said that a surgeon may come across an ethical dilemma if a patient could benefit from using the femtosecond laser but it is not indi- cated based on CMS guidelines. February 2011 Femtosecond phaco techniques March 2014 tively," he said. "There's nothing that it creates by itself, other than some of these anatomic issues … that are present intraoperatively; if you had a complete tear in the cap- sule, that can cause complications postoperatively, but that would happen whether it's a laser or not that caused it." "I can't think of anything the laser does that causes complications postoperatively," Dr. Culbertson said. EW Editors' note: Dr. Cionni has financial interests with Alcon and WaveTec Vision (Aliso Viejo, Calif.). Dr. Culbertson has financial interests with Abbott Medical Optics. Dr. Nagy has financial interests with Alcon. Contact information Cionni: 801-266-2283 Culbertson: wculbertson@med.miami.edu Nagy: nagy.zoltan_zsolt@med.semmelweis-univ.hu Femtosecond continued from page 117 AT A GLANCE • There are very specific cases where patients can be billed for use of the femtosecond laser. These include using an imaging component for a premium IOL and for use in astigmatism correction. • There is a lot of debate over t he actual effectiveness of the femtosecond laser and whether it is superior to other options; long-term data on the technology are not yet readily available. • Physicians should discuss all possible situations with patients, including when patients want the technology but can't afford it or the physician doesn't offer it. continued on page 120 108-125 Feature_EW March 2014-DL2_Layout 1 3/6/14 3:59 PM Page 118