Eyeworld

with that. Also, we learn things by doing the rhexis. I get a very good feel for what I've got in the eye, like what the posterior pressure is and what the zonules are like." "It cannot remove the cataract, insert an intraocular lens implant, or seal the incisions upon completion of the surgery," said D. Brian Kim, M.D., Dalton, Ga. "So what does the laser give us that's really innovative and revolutionary? Nothing." Cost considerations The system is far from cheap, with purchasing costs estimated into the six-figure range with a click fee in the three- to four-figure range, and this seems to be one of the major de- terrents for most ophthalmologists. "It's phenomenally expensive with little benefit," said Dr. Oren. "I can tell you what I hear in my prac- tice on a daily basis: 'The surgery costs too much, multifocal implants cost too much, the antibiotic I need for surgery costs too much, the co- pay costs too much.' It is constant." "If the technology is exorbi- tantly costly including click fees, ophthalmologists are going to have a hard time adopting it," said Dr. Kim. "Since the benefits appear to be marginal, I believe the cost needs to be much more affordable or else there will be little incentive for us to adopt the technology." The other issue tossed around is billing. Who is going to pay for it? Many surgeons believe billing pa- tients for a laser they don't need in order to undergo a successful surgery is unethical and unfair. "When surgeons go to their pa- tients and say, 'You have to pay for this technology because it's better,' so they, in turn, can pay for this laser, I don't think that's right," said Dr. Safran. "It's not better. You can't just charge certain patients who use the laser extra; you have to charge everyone the same thing. All you can do is charge extra for the LRI or for premium lenses." "Medicare does not care how you take the cataract out," said Gary Wortz, M.D., Lebanon, Ky. "If you use a butter knife or a laser, they are going to pay you the same. Some people are saying you can charge for a refractive component of the proce- dure, but what we're really talking about at that point is an LRI. Will it be cost effective and appropriate to charge for a laser LRI? Hopefully the free market nature of non-covered refractive surgical procedures will answer this question." Complications Is laser-assisted cataract surgery bet- ter than what we have now? Oph- thalmologists don't seem to have a clear answer for this. One reason cited is the overall lack of data about the complication rate and consis- tency of refractive outcomes. "We don't know what the po- tential risks of making a rhexis be- forehand and waiting to do the surgery an hour or so later are. Will the pupil lose dilation? Will expos- ing the eye to lens proteins lead to increased inflammation and in- creased complications such as CME, glaucoma, and cornea problems?" These are questions that Dr. Safran posed. "What is the posterior capsule tear rate? What are the vitrectomy rates with femto phaco?" Dr. Wortz asked. He added, "Those are the questions I'm looking at, and I don't have any answers." Dr. Safran commented, "Our most technically demanding cataract surgeries … small pupil, loose zonules, and extremely dense lenses, will not be facilitated by the use of this device. The surgeon who might gain benefit from using this laser to help him with his rhexis for- mation on some patients may find he has even more difficulty dealing with the challenging cases where he can't use this device as a crutch." There is also a question of effi- ciency. Drs. Safran and Oren don't believe the product will make them any faster in the OR and speculate that it might slow them down. "I don't know if it will take time off the case because it's not in one box now," said Dr. Oren. Even if it allows one to reduce surgical time by a minute or two, "Is that beneficial? I don't know. I don't think so. I get my cases done now." "What you're doing with this is introducing problems and making cataract surgery more complex," said Dr. Safran. "I can do a cataract sur- gery efficiently and effectively in a one-stop-shop. What do I need this laser for?" "The evidence will need to be shown through prospective clinical studies looking at complication rates, consistency of refractive out- comes, etc., directly compared to our current methods," said Dr. Kim. "From an ophthalmologist's perspec- tive, I believe many of us are skepti- cal of its value and question the legitimacy of charging high prices to patients for something yet un- proven." July 2011 Laser-assisted cataract surgery continued on page 36

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