Eyeworld

EW FEATURE 54 Femto cataract clinical update July 2015 by EyeWorld staff L aser-assisted cataract surgery (LACS) offers many benefits, according to some surgeons. "One benefit is that it allows me to develop a surgical plan in the office, and using an image-guided system, I can execute that plan more precisely under the laser," said Kerry Solomon, MD, Charleston, S.C. "My incisions can be placed exactly. Additionally, the system accounts for cyclorotation, so that I should be able to more precisely account for surgically induced astigmatism. The real-time OCT aspect allows us to be able to place arcuate incisions precisely where we want them, at the optimal depth throughout the entire length. It also ensures a nice, round capsulo- tomy, and less ultrasound energy is required in the eye because the lens is pre-softened with the femtosec- ond laser. The bottom line is clear corneas, earlier visual recovery, and a less traumatic procedure." In the 2014 Clinical Survey, ASCRS members were surveyed about their adoption of LACS. When asked what percentage of cataract patients receives femtosecond laser cataract surgery, U.S. surgeons reported using it more often than non-U.S. surgeons (5.8% for U.S. surgeons versus 3.6% for non-U.S. surgeons). According to Eric Donnenfeld, MD, Rockville Centre, N.Y., "5.8% of U.S. patients is an extremely high penetration rate for a new technolo- gy, and [this] is much faster than the adoption of phacoemulsification at a similar time point in its develop- ment." When asked about their con- fidence in an adequate reimburse- ment solution (either private pay or insurance), less than 20% of respondents reported being confi- dent or extremely confident that there is currently an adequate reimbursement solution to support LACS: 18.0% overall (18.9% for U.S. respondents and 16.7% for non- U.S. respondents). The difference in responses between U.S. and non- U.S. surgeons was not statistically significant. Dr. Donnenfeld said that the finding that less than 20% of respondents believe there is an adequate reimbursement pathway is very reasonable based on most physicians' experience with patient Laser-assisted cataract surgery today: ASCRS members weigh in shared billing. "The fact that LACS is a non-covered expense for refrac- tive solutions in patients undergo- ing cataract surgery is difficult for many cataract surgeons to accept as this is a new paradigm and this creates concern as evidenced by the responses in this survey. As data showing clinical benefits become more robust, I believe that oph- thalmic surgeons will increasingly recommend LACS to their patients. However, I do not predict the reimbursement model will change significantly but that surgeons will become more comfortable with the present model," he said. He follows the FDA guidelines of only charging patients for LACS who are seeking a refractive solution, which includes patients who are receiving arcuate incisions for the management of their astigmatism with conventional IOLs or patients having premium IOL surgery such as toric, multifocal, or accommodating IOL surgery with or without arcuate incisions. David Dillman, MD, Danville, Ill., uses a mobile femtosecond laser, so his reimbursement model is dif- ferent from surgeons who own their lasers. "I pay a per-case fee (that includes the docking device fee) to the mobile company," he said. When asked about the benefits of LACS compared with convention- al cataract surgery, more than half of all respondents believe LACS may provide a significant clinical benefit versus conventional cataract surgery in the areas of arcuate refractive incisions (59.3%), capsulorhexis creation (58.8%), and lens fragmen- tation (52.1%). U.S. respondents believe more strongly that all of the areas listed may provide a more significant benefit compared to non- U.S. respondents. On average, U.S. respondents selected 2.2 benefits while non-U.S. respondents selected 1.8. The biggest difference between U.S. and non-U.S. surgeons was arcuate refractive incisions, selected by 70.7% of U.S. respondents and 46.2% of non-U.S. respondents, a difference of 24.5%. The differ- ence in response between U.S. and non-U.S. surgeons was statistically significant (Figure 1). According to Dr. Donnenfeld, the greatest benefit for patients will vary from surgeon to surgeon. "In this survey the greatest benefit of LACS was divided into 3 groups: lens fragmentation, capsulorhexis, and arcuate incisions. In my opinion, these are all significant benefits for our patients. Surgeons who do not currently treat astigmatism with manual arcuate incisions will likely find the laser arcuate incision to be the greatest benefit. On the other hand, other surgeons will find the benefit that most suits their individ- ual surgical technique and patient outcomes. In my personal experi- ence, I find the lens fragmentation to be the greatest benefit and my ability to perform cataract surgery with no ultrasound power to be a nice benefit to patients," he said. According to Dr. Dillman, the greatest benefit of LACS can be seen in difficult cases. "In really dense lenses, in tough capsulorhexis cases, in weak zonules cases, and in cases with significant endothelial guttata, LACS makes it easier. For example, in many cases of dense lenses, LACS has reduced the amount of delivered phaco energy by 60% to 75% over my traditional, all manual tech- niques," he said. Pearls for practice Dr. Solomon said that surgeons who are interested in incorporating this technology into their practic- es should do a site visit. "Go visit someone who is using the laser that you are thinking of using, so you can see it and learn from your peers. Patient selection is key for getting started. I wouldn't choose challeng- ing or uncooperative patients. Pick cases that look like patients will be cooperative and that will allow easy access," he said. Dr. Dillman agreed. "In the summer of 2012, I visited 3 cataract ASCs and watched 5 surgeons do approximately 100 LACS surgeries. I watched their preop, intraop, and postop setups, and I asked them a ton of questions. By the end of that summer, I felt I had a decent handle on LACS," he said. "Femtosecond LACS is develop- ing very quickly and is an extremely exciting technology. Individual sur- geons should follow these develop- ments closely and consider adopting LACS when they are satisfied the technology is providing a significant service to their patients," Dr. Donnenfeld said. EW Editors' note: Dr. Donnenfeld has financial interests with Abbott Medical Optics (Abbott Park, Ill.), Alcon (Fort Worth, Texas), and Bausch + Lomb (Bridgewater, N.J.). Drs. Dillman and Solomon have no financial interests related to their comments. Contact information Dillman: Dadomer@aol.com Donnenfeld: ericdonnenfeld@gmail.com Solomon: kerry.solomon@carolinaeyecare.com Arcuate refractive incisions Self-sealing corneal incisions Capsulorhexis creation Lens fragmentation I don't believe this will offer a significant clinical benefit in any of these areas 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% U.S. Non-U.S. Overall Figure 1

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