July 2011




Laser-assisted cataract surgery

Why not femto?

by Faith A. Hayden EyeWorld Staff Writer

Not everyone is on board with femtosecond cataract surgery; here's why

There are some topics too contentious to discuss among friends: politics, religion, and, at least for ophthalmologists, laser-assisted cataract surgery. The emerging technology is such a hotly debated issue that the mere mention of its name invokes diatribes from the politest of surgeons. Ask an ophthalmologist why he or she isn't implementing the new system and you'll get an earful of reasons ranging from cost to practicality to efficacy. One characteristic rang true across the board though. All the physicians EyeWorld interviewed feel incredibly passionate about their opinion on the laser and its usage.

Do we need it?

Relevance is one of the go-to criticisms surgeons have. Do ophthalmologists really need help making a capsulorhexis or a limbal relaxing incision (LRI)? Can the laser do anything that a well-qualified surgeon can't already do? Steven G. Safran, M.D., Lawrenceville, N.J., and Brad Oren, M.D., Lake Worth, Fla., don't seem to think so. "There is nothing that this technology can do for me that I need help with," said Dr. Safran. "I can make a perfect capsulorhexis 100% of the time with a bent needle and capsulorhexis forceps and in my opinion, it takes less time than it would if a femto laser was added to the mix." "In my hands, this machine doesn't benefit the patient at all," said Dr. Oren. "I haven't had a wayward capsulorhexis since I was a resident. Any good surgeon hasn't." Dr. Safran likens the assistance the femtosecond laser gives cataract surgeons to bathroom attendants in high-dollar nightclubs and restaurants: Thanks, but I can grab the towel and soap myself. "If we really needed something to make a capsulorhexis, why did the Fugo blade die in its crib?" he asked. "For 20 grand, you could make a perfect capsulorhexis without a click fee. Did anyone buy it? No. Why? Because we didn't need it." Other benefits of laser-assisted cataract surgery touted include less endothelial cell loss and less phaco power necessary, but some surgeons are skeptical of these so-called benefits as well. "I haven't seen any well-done studies to prove that this is true," said Dr. Oren. "In today's practice, we don't see a lot of endothelial cell loss. We remove the lens today primarily with irrigation and aspiration as much as we do with phaco power, especially for those of us who chop." Although there are aspects of cataract surgery that the laser can now automate, it can't do everything, nor can it do the most important aspects of the procedure, at least according to some critics. "Most of the problems with cataract surgery don't occur while making the rhexis," said Dr. Safran. "They occur with other parts of the procedure. Cortical cleanup is the biggest issue. This isn't going to help 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 deterrents for most ophthalmologists. "It's phenomenally expensive with little benefit," said Dr. Oren. "I can tell you what I hear in my practice 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 exorbitantly 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 patients for a laser they don't need in order to undergo a successful surgery is unethical and unfair. "When surgeons go to their patients 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 procedure, 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."


Is laser-assisted cataract surgery better than what we have now? Ophthalmologists don't seem to have a clear answer for this. One reason cited is the overall lack of data about the complication rate and consistency of refractive outcomes. "We don't know what the potential risks of making a rhexis beforehand and waiting to do the surgery an hour or so later are. Will the pupil lose dilation? Will exposing the eye to lens proteins lead to increased inflammation and increased 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 formation 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 efficiency. 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 surgery 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 outcomes, etc., directly compared to our current methods," said Dr. Kim. "From an ophthalmologist's perspective, I believe many of us are skeptical of its value and question the legitimacy of charging high prices to patients for something yet unproven." Dr. Safran said, "What we are doing now is the gold standard against which the laser will have to prove itself. Not the other way around. To charge extra for something that has not yet proven itself in this manner seems wrong to many of us. To claim it is better at this point is just false."

Final points

Nothing in life is all bad, and some of the surgeons EyeWorld spoke with were quick to point this out. Drs. Oren, Safran, and Wortz, for example, acknowledged that laser-assisted cataract surgery has the potential to level the playing field, taking a poor or average surgeon and making him or her above average. But is that necessarily a good thing? "What is going to happen is it's going to make the surgeons with a high complication rate much better, but it may not make surgeons with a low complication rate better," said Dr. Wortz. "In fact, it might make them worse. The laser's complication rate is going to be everyone's complication rate." "Sure, there are guys out there who are lousy surgeons that might benefit," said Dr. Safran. "But is it fair to allow lousy surgeons to charge patients more so they can have a decent capsulorhexis?"

Dr. Wortz admitted that although he doesn't believe the technology has a tangible benefit right now, that doesn't mean it won't in the future. "I think there may be advantages down the road that we can't foresee right now," he said. "I never want to bet against new technology. Maybe we don't see all the benefits right now, but that may be because we're not creative enough in our thinking and haven't caught the vision of what it's going to be."

Editors' note: None of the physicians interviewed have financial interests related to their comments.

Contact information

Kim: kim@professionaleye.com
Oren: rlodad@bellsouth.net
Safran: safran12@comcast.net
Wortz: 2020md@gmail.com