Eyeworld

EW FEATURE 50 Femto cataract clinical update July 2015 AT A GLANCE • Cost issues are one reason some surgeons are avoiding FLACS. • Some remain unconvinced that the use of the femtosecond laser is beneficial to patients. • Other technologies in the wings may decrease the femtosecond laser's impact. by Maxine Lipner EyeWorld Senior Contributing Writer lower ultrasound usage in conjunc- tion with FLACS are true, if the laser is used for corneal incisions, there is increased cell loss from these, which may offset any beneficial effect of lower ultrasound time, he pointed out, adding that at the 6-month mark there is no difference in en- dothelial cell density between the procedures. Use of the femtosecond laser for cataract surgery has also not proven to be safer, Dr. Schulze said. He cited the ESCRS study on FLACS reported by Peter Barry, MD, in September 2014, which indicated that the femtosecond complication rate was 3.2% versus 1.8% for traditional phacoemulsification. Given all, he finds the upcharge for the patient troubling. Dr. Schulze offered a quote from another prac- titioner who ultimately returned his femtosecond laser to the manu- facturer: "I couldn't look a patient in the eye and ask him to spend an extra thousand dollars for a technol- ogy that wouldn't make his outcome any better." That practitioner, he said, was from a large practice where they could buy such technology performing the OCT imaging for a premium refractive IOL, Dr. Chang said, adding that CMS could have gone other ways with this. "They could have forbidden any patient billing for the femtosecond laser aside from astigmatic keratotomy." This probably would have forced companies to abandon click fees. Alternatively, they could have ruled that robotic technology, like FLACS, is not medically necessary and therefore if patients opt for this, it is up to them to pay for it. This would have created a situation akin to the one that exists in Australia, he said, where patients are completely free to pay the additional FLACS costs for any reason. "As it stands in the United States, we are not allowed to bill pa- tients for the cataract surgical steps performed with the femtosecond laser," Dr. Chang said. "I regret that American seniors who don't mind wearing glasses don't have the right to pay their own money for FLACS if they want it." Currently, however, he is also not convinced of the additional refractive benefits of using the femto laser. "We never purchased a femto- second laser because I don't believe there to be a refractive benefit to my own patients," he said, adding that he prefers to use a toric IOL rather than femtosecond laser astigmatic keratotomy for those patients who want and can afford astigmatism correction. Richard R. Schulze Jr., MD, Savannah, Ga., believes that he has an ethical obligation to put his pa- tient's financial well being ahead of his own. "If I can be convinced that femtosecond lasers are better for my patients, I will use them," he said. As it stands, however, when performed by a skilled surgeon, femtosecond laser-assisted cataract surgery offers no significant benefit to the patient, he said, adding that if this hypoth- esis can be disproven, all practi- tioners should move to femtosecond laser-assisted cataract surgery. While there have been many claims by the femtosecond industry of "lower ultrasound times," "better incisions," and "safer procedures," the actual benefits of incorporating the technology remain in dispute, Dr. Schulze said. Although claims of Forgoing the femtosecond laser Manual capsulorhexis in a patient with a mild subluxated lens. While Dr. Hoffman said that the femtosecond laser may be beneficial in cases of rock hard cataracts or subluxated lenses, these are rare in his practice. Why some practitioners are making the choice W hile femtosecond cataract surgery has become a hot topic in recent years on the podium, some practitioners continue to perform the traditional phacoemulsification. EyeWorld asked those who have not embraced the new technology about their thinking on this. David F. Chang, MD, clinical professor of ophthalmology, Uni- versity of California, San Francisco, thinks that as with any operation, cataract surgeons should be free to individualize their techniques and instrumentation according to their own experience and skill set. Dr. Chang said he is not "anti-FLACS," and he welcomes new technologies that may improve patient care. "However, what makes femtosec- ond laser-assisted cataract surgery [FLACS] so different is the high cost that must be borne by the patients," he said. "This requires a much high- er burden of scientific evidence and justification." Yet most of the largest studies are failing to show benefits that would justify some of the mar- keting of this technology, he said. Globally, the adoption of FLACS mirrors the degree of economic freedom given to patients by their healthcare system, Dr. Chang said. "Some countries allow patients to pay out of pocket for FLACS for any reason. Other countries require patients to opt out of their insurance system to pay privately for a FLACS procedure." In the U.S., however, there are constraints. A key regulatory decision was made by the Centers for Medicare and Medicaid Services (CMS) to permit billing patients only for the refractive benefits of astigmatic keratotomy or for

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