Eyeworld

EW FEATURE 32 by Vanessa Caceres EyeWorld Contributing Writer Excimer lasers at the ready for refractive cataract patients How to gain access for post-cataract PRK touch-ups I f you're delving into refractive cataract surgery but need to access an excimer laser for PRK touch-ups, there are a few options. First, plan ahead. "In an age of premium IOLs, some patients will need refractive enhancement," said Sonia H. Yoo, MD, professor of ophthalmology, Bascom Palmer Eye Institute, Miller School of Medicine, University of Miami. "It behooves the surgeon to work it out in advance before you are scrambling for an option." "Patients look at this as a pre- mium procedure, but it often in- volves some additional steps with the refractive endpoint. The excimer laser is a great choice, but it requires a little planning and effort," said John A. Vukich, MD, partner at Davis Duehr Dean Center for Refractive Surgery, Madison, Wis. One option to consider is an open access model. Under open access, a surgeon uses, as needed, a laser owned by a group of physicians or a teaching hospital. These types of arrangements are more common in urban areas. Naturally, there is a cost to use them, and the surgeon has to go through the proper train- ing with the laser. Laser training and certification is available at the major ophthalmology meetings and online, Dr. Yoo said. At Bascom Palmer, community physicians will come in to use its lasers for a fee, she said. The physi- cian can decide about covering that fee or sharing the cost with patients. Roll on/roll off Yet another option is using a mobile laser—often called a roll on/roll off laser, said Richard L. Lindstrom, MD, adjunct professor emeritus, University of Minnesota, Minneapo- lis. Dr. Lindstrom has used mobile lasers from the company Sightpath Medical (Bloomington, Minn.), both for excimer and femtosecond tech- nology. His office contracts with Sightpath and asks them to bring the laser in on a certain day of the month or week. Sightpath provides the laser on the given day, but Dr. Lindstrom and fellow surgeons must do a minimum number of procedures with it. Sightpath has about 200 mobile lasers for ophthalmic surgery in 49 states, said Joel Gaslin, vice president of sales and marketing at Sightpath Medical. There are femtosecond, excimer, selective laser trabeculoplasty, and YAG lasers. The company's lasers perform about 75,000 cataract procedures and 35,000 LASIK procedures annually, he said. The company works with 900 surgeons at 700 facilities. There is, of course, a strong interest right now in its mobile femtosecond cataract laser platform, MoFe. Sightpath will have 30 lasers in the field by year's end, Mr. Gaslin said. The company usually requires a minimum of four cases to set up the laser for use. A Sightpath engineer sets up the laser and makes sure it works properly, Mr. Gaslin said. Sightpath does not provide medical staff, as the company does not as- sume medico-legal risk, he added. "For lower volume surgeons, it's a popular model," said Dr. Lindstrom, who has done some advising with Sightpath. If mobile laser use seems like a reasonable choice, consider a few logistical points first, Dr. Lindstrom and Mr. Gaslin recommended. • Make sure you have a door at least 40 inches wide so the laser can be brought into your facility. "We send someone in advance to survey the site and recommend any modifications needed," Mr. Gaslin said. • If you work with multiple ORs, choose which one will house the laser. In Dr. Lindstrom's ambula- tory surgical center, the mobile femtosecond cataract laser is usually housed in a specific OR among three available ORs. • Consider scheduling. Because the laser will only be there on certain days, have your staff group procedures together on the chosen days. • Ask Sightpath or any other mobile laser rental company if you can observe someone else receiving and using the laser, so you can see the logistics involved, Dr. Lindstrom recommended. Buying your own Buying your own excimer laser for refractive touch-ups after cataract surgery is an option, but it is a hefty consideration. "It's a huge expenditure. I'm not sure you could buy the laser and maintain it exclusively for touch-ups unless you have an enormous vol- ume. It's hard to see how you could make sense of that," Dr. Vukich said. To make an excimer laser pur- chase viable, you'd need to operate on at least 500 eyes a year with the laser, Dr. Lindstrom said. So if you did 2,500 cataracts a year with a premium IOL conversion rate of 20%, that adds up to 500 eyes a year. However, would all of those patients need a refractive laser touch-up? Probably not. In fact, Dr. Vukich estimates that only 10% to 15% of patients usually require a touch-up. The dollars and cents are why Dr. Lindstrom continues to use mobile lasers. "We've been doing refractive corneal surgery since 1996. Almost 20 years later, we're still accessing the excimer and femtosec- ond lasers from Sightpath because we've found it's an economically better decision," he said. As a side note, while LASIK is a common procedure, it would in- volve the use of both the excimer laser and a femtosecond laser to cre- ate the flap. That is why the surface ablation via PRK would be a wiser choice if laser access does not come easily, Dr. Vukich said. Piggyback lenses are another option if you cannot access a laser, he added. EW Editors' note: Dr. Lindstrom has financial interests with Alcon (Fort Worth, Texas), Abbott Medical Optics (Santa Ana, Calif.), Bausch + Lomb (Bridgewater, N.J.), and SightPath Medical. Dr. Yoo has financial interests with Alcon, Abbott Medical Optics, and Carl Zeiss Meditec (Jena, Germany). Dr. Vukich has financial interests with Abbott Medical Optics and Carl Zeiss Meditec. Mr. Gaslin is an employee of Sightpath Medical. Contact information Gaslin: Joel.Gaslin@sightpathmedical.com Lindstrom: rllindstrom@mneye.com Vukich: javukich@gmail.com Yoo: syoo@med.miami.edu Keratorefractive enhancement of pseudophakes July 2014 AT A GLANCE • If you need an excimer laser for PRK/refractive touch-ups after premium IOL surgery, there are a few available options. • An open access laser owned by another physician group or teaching hospital gives as-needed access to an excimer laser. • A mobile laser—roll on/roll off— brings a laser to your facility as needed, provided you perform a minimum number of procedures. • Although buying a laser is an option, carefully consider the costs involved. Some surgeons use mobile lasers for refractive surgery, including lasers provided by SightPath Medical. Source: SightPath Medical 30-37 Feature_EW July 2014-dl_Layout 1 6/30/14 8:42 AM Page 32

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