Eyeworld

EW FEATURE 34 by Faith A. Hayden EyeWorld Staff Writer Why not femto? rang true across the board though. All the physicians EyeWorld inter- viewed feel incredibly passionate about their opinion on the laser and its usage. Do we need it? Relevance is one of the go-to criti- cisms surgeons have. Do ophthal- mologists really need help making a capsulorhexis or a limbal relaxing incision (LRI)? Can the laser do any- thing that a well-qualified surgeon can't already do? Steven G. Safran, M.D., Lawrenceville, N.J., and Brad Oren, M.D., Lake Worth, Fla., don't seem to think so. "There is nothing that this tech- nology can do for me that I need help with," said Dr. Safran. "I can make a perfect capsulorhexis 100% of the time with a bent needle and capsulorhexis forceps and in my opinion, it takes less time than it would if a femto laser was added to the mix." "In my hands, this machine doesn't benefit the patient at all," said Dr. Oren. "I haven't had a way- ward capsulorhexis since I was a resi- dent. Any good surgeon hasn't." Dr. Safran likens the assistance the femtosecond laser gives cataract surgeons to bathroom attendants in high-dollar nightclubs and restau- rants: Thanks, but I can grab the towel and soap myself. "If we really needed something to make a capsulorhexis, why did the Fugo blade die in its crib?" he asked. "For 20 grand, you could make a perfect capsulorhexis with- out a click fee. Did anyone buy it? No. Why? Because we didn't need it." Other benefits of laser-assisted cataract surgery touted include less endothelial cell loss and less phaco power necessary, but some surgeons are skeptical of these so-called bene- fits as well. "I haven't seen any well-done studies to prove that this is true," said Dr. Oren. "In today's practice, we don't see a lot of endothelial cell loss. We remove the lens today pri- marily with irrigation and aspiration as much as we do with phaco power, especially for those of us who chop." Although there are aspects of cataract surgery that the laser can now automate, it can't do every- thing, nor can it do the most impor- tant aspects of the procedure, at least according to some critics. "Most of the problems with cataract surgery don't occur while making the rhexis," said Dr. Safran. "They occur with other parts of the procedure. Cortical cleanup is the biggest issue. This isn't going to help February 2011 Laser-assisted cataract surgery July 2011 The next continued from page 33 ment of pre-existing astigma- tism, for example, which is a refrac- tive effect that is not covered, he said. Dr. Slade agreed, "I think the best business model is to have a high percentage of premium IOL pa- tients and to be dealing with a lot of astigmatism, in other words, a re- fractive cataract practice." He warned that practices cannot add an extra charge for using the laser on top of the costs for implant- ing premium IOLs; however, they can charge whatever they wish when doing premium IOL surgery. "Now if you're treating astigma- tism with it, which you need to be, then you can charge whatever you wish when you treat astigmatism," he said. Dr. Slade also said he thinks most practices could have the fi- nances to get access to the laser. "Seventy-two percent of our patients have astigmatism of .5 D or more, which could be treated with this laser. I think that most patients have the [financial] ability and, if they knew about it, would want to have glasses-free vision. I think they would pay for that; I think the value to the patients is certainly there." However, he added that it does require that the practice discuss the option with them. "There are prac- tices that are more geared toward pure cataract and not refractive, and I don't see how it's going to work if the practice only does Medicare cataracts and never asks for any extra charges." Adoption rate and market share Dr Slade said he thinks adoption of the technology will occur pretty rap- idly, although it could take time be- fore it's 50%. On the other hand, there are more people who want the lasers at this point than the manu- facturers can build devices, so right now the limiting factor is that there aren't enough lasers to sell, he said. Dr. Solomon said he thinks the practices that acquire it will inte- grate it and adopt it very quickly be- cause there's a great deal of interest out there. He said that there may be prac- tices in the different communities that feel pressure to acquire the technology because of the fear that they may lose patients to practices that have it. However, when the IntraLase (Abbott Medical Optics, Santa Ana, Calif.) first came out, that was not the case, he said. Practices that are comfortable with the procedures that they're doing and have had good success will educate their patients that with the technique they use and the re- sults that they get, there is not a need for this and that's fine, Dr. Solomon said. "My sense is that people are not going to lose market share over this technology, but I believe the tech- nology is the way of the future and more practices will be adopting it over time," he said. EW Editors' note: Drs. Mackool, Slade, and Solomon have financial interests with Alcon (Fort Worth, Texas). Contact information Mackool: 718-228-3400, mackooleye@aol.com. Slade: 713-626-5544, sgs@visiontexas.com Solomon: 843-792-8854, kerry.solomon@carolinaeyecare.com Not everyone is on board with femtosecond cataract surgery; here's why T here are some topics too contentious to discuss among friends: politics, re- ligion, and, at least for oph- thalmologists, laser-assisted cataract surgery. The emerging tech- nology is such a hotly debated issue that the mere mention of its name invokes diatribes from the politest of surgeons. Ask an ophthalmologist why he or she isn't implementing the new system and you'll get an earful of reasons ranging from cost to practi- cality to efficacy. One characteristic AT A GLANCE • Some surgeons feel that the laser's capabilities are redundant • Lack of data on the laser's compli- cation rates makes some surgeons uncomfortable • The laser cannot complete some of the most critical aspects of cataract surgery • Some surgeons view the laser as phenomenally expensive with little benefit to the patient

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