Eyeworld

EW NEWS & OPINION 16 July 2017 Insights by J.C. Noreika, MD, MBA for them rationalize access to the laser for the rhexis and lens soften- ing (both "covered" services). How much astigmatic error can be tolerat- ed without undermining function of the average patient? Are patients led to believe that the femtosecond laser yields superior results in present-day implant surgery? Do they assume they will undergo "laser cataract surgery"? Is it intimated that the la- ser's imaging function is required for proper implant placement? Nuanced indeed. According to the Motley Fool, the median annual income of an Amer- ican between the ages of 70 and 74 is less than $25,000. A thought experiment? How many FLACS surgeons deliberating their own routine bilateral cataract surgery would commit 30% or more of their yearly take-home for a procedure arguably no better than that paid for by Medicare? It is reported that sales of fem- tosecond lasers worldwide are flat. When ophthalmologists are sur- veyed as to what constitutes the big- gest hurdle to adoption, cost is cited. But, eye surgeons are a perfectionis- tic lot; many are innovators; some are visionaries; a few are risk-takers. They will contrive systems that de- liver the laser's benefits with greater convenience and efficiency at much lower cost. Another perfectionistic entrepre- neur once took calligraphy courses at Reed College before dropping out. His company produces my MacBook Air and its stunning array of typog- raphy. Technology is funny like that. The femto odyssey continues. EW References 1. Srinivasan S. Capsulorhexis: The perfect circle. J Cataract Refract Surg. 2017;43:303– 304. 2. Chang DF. Does femtosecond laser-assisted cataract surgery improve corneal endothelial safety? The debate and conundrum. J Cata- ract Refract Surg. 2017;43:440–442. Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Contact information Noreika: JCNMD@aol.com I have concerns. As in 2012, there is no explicit insurance mech- anism to pay for using this $550,000 machine to extract an opacified lens. Even applying adroit accounting principles, ophthalmic surgeons confront both substantial invest- ment risk and sizable maintenance liabilities. Compounding this, the logistics of the process make it more inconvenient and time-consuming to perform. Would I pay for the femtosec- ond laser if I had one of Dr. Masket's exigencies? Unequivocally. But what if I had a moderately nuclear sclerot- ic cataract with a normal endothelial cell count, a deep anterior chamber, excellent pupillary dilation, and no history of zonular trauma or pa- thology? Would I personally assume the upcharge for a premium lens or laser relaxing incisions to exploit the laser? (Medicare mandates that only fees for non-covered services, e.g., laser relaxing incisions, can be charged out-of-pocket.) Probably not. And I have a net worth north of the nation's $195,000 median for my 64- to 69-year-old demographic segment. FLACS does not guarantee an untroubled surgical result. Variables affecting outcome include unrecog- nized anterior and posterior corneal astigmatism, lenticular astigmatism, malposition of a toric implant, man- ufacturing limitations of intraocular lens power accuracy, their availabili- ty in 0.5 diopter increments, higher order aberrations with multifocal lenses, pre-existing retinal and optic nerve pathologies, idiosyncrasies of healing tissue, psychological quirks of the paying customer, unrealistic expectations, and buyer's remorse. Converting patients to pay for FLACS presents ethical dilem- mas. LRI and premium lenses are non-covered services; fees charged i.e., femtosecond laser-assisted cata- ract surgery or FLACS, its enthusiasts can grow defensive. The best current data struggles to validate the femto- second laser's indisputable advan- tage in routine cataract surgery. Is it transformative? Maybe. Sam Masket, MD, does not participate in insurance plans. When he uses the femtosecond laser, it costs him money. Does Dr. Masket find the femto valuable? Those enduring to the end of this year's ASCRS•ASOA Symposium & Con- gress heard his talk, "Laser cataract surgery as an enabling technology." He reported that FLACS improved his chances of safe and effective outcomes in five specific instances: patients with compromised corneal endothelium, dense cataracts, zonu- lopathies, shallow anterior cham- bers, and capsular anomalies as seen in posterior polar cataracts. But what of its application in "routine" cataract surgery? It can produce a near-perfect capsulor- hexis, "potentially offering more predictable refractive outcomes." 1 By fracking the nucleus prior to emulsi- fication, ultrasound energy may be reduced. Some proponents envision a future of phacoemulsification-free nucleus removal. This may prove kinder to the corneal endothelium. David Chang, MD, has pondered whether the small difference in endothelial cell density after FLACS and modern non-laser-assisted cata- ract surgery is significant. 2 Although the European Registry of Quality Outcomes for Cataract and Refrac- tive Surgery study reported compli- cations are higher in FLACS than routine phacoemulsification, most are minor. Serious complications like dropped nuclei and vitreous loss are rare. One noted speaker reassured his audience that FLACS "is not worse" than phacoemulsification relative to refractive outcomes. In articles published in 2012 and 2013, the author considered the value of femtosecond cataract surgery. Has his opinion changed? Dear Dr. J, In 2012 and 2013, you wrote in EyeWorld that the application of the femtosecond laser to cataract surgery would not prove a transformative advance. You called it an "appealing technology" whose value wasn't irrefut- able. After this year's ASCRS meeting, has your opinion changed? Sincerely, Hopeful in Hoboken Dear Hopeful, The femtosecond laser is aston- ishing technology. A femtosecond is 1 millionth of a billionth of a sec- ond. How to make incomprehensi- ble numbers comprehensible? Con- sider distance. If a femtosecond were a femto-inch, it would take 15.78 billion of them to make a mile. That's more than twice the world's population. Now selling 75 burgers a second, it will take McDonalds 6.67 years to reach that number. Even our spendthrift federal government needs 36 hours to spend that much cash. Is the femto already passé? According to MIT News, researchers easily work in the realm of femto- seconds. "Continuing the progress, today's top-shelf technologies are beginning to make it possible to observe events that last less than 100 attoseconds, or quintillionths of a second." Unlike the dude, technol- ogy never abides. The femtosecond laser has revolutionized and defines contem- porary corneal refractive surgery. No human can fashion flaps as exqui- sitely as this low-energy infrared light source. But when conversation turns to value in cataract surgery, Femtosecond redux J.C. Noreika, MD, MBA " The best current data struggles to validate the femtosecond laser's indisputable advantage in routine cataract surgery. "

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