September 2011




ASCRS/EyeWorld Town Hall Meeting on Laser-Assisted Cataract Surgery


Reporting live from the ASCRS/ EyeWorld Town Hall Meeting on Laser- Assisted Cataract Surgery, Chicago, July 14-17, 2011

Editors' note: This Meeting Reporter contains original reporting by the EyeWorld news team.



General sessions of the ASCRS/EyeWorld Town Hall Meeting on Laser-Assisted Cataract Surgery opened Friday, July 15, 2011, with presentations by panelists experienced with the technology, as well as those surgeons who debate its present usefulness. Attendees were encouraged to ask questions and discuss their opinions with the faculty.

Examining the science/debates

Eric D. Donnenfeld, M.D., Long Island, N.Y., opened the first session by inviting everyone to participate in roundtable discussions that culled participants' wish lists for what they wanted to get out of the meeting. As part of a real-time survey, 88% responded that they believed there is room for improvement in the cataract surgery procedure, but indicated that they wanted more information. When asked if there is a clear pathway to reimbursement, approximately 75% said they didn't think so.

Following the survey, panelists turned toward the science of and debates surrounding laser-assisted cataract surgery. Barry S. Seibel, M.D., Los Angeles, opened with a presentation on the current status of cataract outcomes and where the procedure needs to go from here. Using an exhaustive literature study undertaken by David F. Chang, M.D., Dr. Seibel attempted to answer the question of whether femto technology would be an improvement over current manual rates.

In contrast to manual cataract surgery, Dr. Donnenfeld said that for him, "Cost and increased time are the only downsides to using the laser, and that's something I'm willing to tolerate." Stephen G. Phillips, M.D., Seattle, continued by asking some critical questions: Can a surgeon buy services a la carte? For example, is it possible to purchase services for performing capsulorhexis and nuclear softening, but not have to pay for incisions and peripheral corneal relaxing incisions (PCRIs)? Will companies offer combination laser packages that will give surgeons access to other applications of the laser? He concluded his presentation by comparing laser-assisted cataract surgery to the now-retired supersonic passenger aircraft Concorde. "The Concorde was fabulous technology but it didn't pay for itself," he said. Steven G. Safran, M.D., Lawrenceville, N.J., presented his more critical perspective on laser-assisted cataract surgery, saying that he was skeptical that outcomes could be significantly improved upon. "There are some advantages to what we're doing now," he said. Dr. Safran said that the emphasis should be on gathering data. He also stated three major hurdles that have to be cleared: the need to preserve fee structure, the need to preserve the surgical domain, and the need to make advocating for the patient a priority.

"Are we really advocating for patients when we sell them a $2,000 rhexis or LRI?" he asked.

Current status of femtosecond laser technology

In the second session of the day, consultants for each of the main companies in the field of femtosecond laser technology presented their perspectives and experiences with the different lasers currently available. Dr. Donnenfeld, who currently uses the LenSx Laser (Alcon, Fort Worth, Texas), opened the session with a summary of the suggested benefits that those who are advocates of laser-assisted cataract surgery are currently touting: more precise and reproducible relaxing incisions, better effective lens positioning, a more precise capsulotomy that translates into better refractive results. Jonathan H. Talamo, M.D., emphasized the importance of making certain that the capsulotomy is complete and that no tags remain. He also compared laser docking for cataract surgery with docking used in LASIK, stating that cataract surgeons need a wider field of view to view the limbus reliably. Dr. Talamo concluded that it is important that one monitor stability of docking and suction during the procedure.

Harvey Uy, M.D., Makati, Philippines, presenting his video demonstrating the use of the LensAR system (Winter Park, Fla.), emphasized that lower levels of laser energy used in laser-assisted cataract surgery replace higher levels of ultrasonic energy. He said to those new to laser-assisted cataract surgery, they will have three steps to master: docking, imaging and measurements, and laser applications.

All agreed that patient selection is importanta patient who is non-compliant, anxious, or incapable of controlling eye movement may not be the ideal patient for the procedure.

The nitty gritty of technique

The third session of the day focused on criteria for patient selection, pre-op and post-op pharmaceutical regimens, the treatment of astigmatism, and the management of intraoperative complications and complicating factors.

Dr. Talamo discussed some of the complications that concern surgeons with regard to laser-assisted cataract surgeryfailure to dock in cases with a tight orbit, blepharospasm, or conjunctivochalasis; globe tilt or decentration; corneal folds; suction loss; and residual bubbles. He explained that in some of these instances, one may continue as planned, but in cases such as suction loss during capsulotomy, incomplete capsulotomy, or residual bubbles, the laser treatment should be aborted and the surgeon should convert to manual treatment.

Kasu Prasad Reddy, M.D., India, briefly discussed the benefits of intelligent pressure control (IPC) offered by the laser he uses and noted that he uses the phaco tip for capsulotomy only in instances where the capsulotomy is complete if incomplete, he extracts the capsule manually.

Dr. Donnenfeld concluded the session by offering up the following lessons learned: 1) use no ointments or gelsthey preclude good suction;
2) patients must be compliant;
3) good dilation is needed;
4) require moderate interpalpebral exposure;
5) redundant conjunctiva can prevent suction;
and 6) pre-op non-steroidals are importantpupils will come down significantly if not used (ideally administered 3 days pre-op).

Candidacy and astigmatism management: Open for debate

In the final session of the day, D. Brian Kim, M.D., Dalton, Ga., along with Drs. Talamo, Reddy, Seibel, and Uy discussed astigmatic candidacy and management with Stephen S. Lane, M.D., Stillwater, Minn., acting as moderator.

The panelists agreed that a patient's pupils need to be centered and dilated to 6-6.5 mm or more in order to undergo astigmatic correction with the femtosecond laser. Dr. Uy added that patients should have clear media, 7-mm central clear cornea, and a centered crystalline lens that is not subluxated. "You should be cautious if you have a subluxed lens," Dr. Uy said.

Dr. Talamo addressed the concern that a cloudy or opaque corneal opacity would be cause for concern. But, "If you can see the iris detail through a corneal opacity, then the laser is going to treat just fine," he said.

In a patient with compromised zonules, such as one who has pseudoexfoliation, the procedure can be performed as long as there is no optic nerve damage, Dr. Talamo added.

Dr. Seibel said that anything that will optically interfere with the imaging or laser, such as poor dilation, significant corneal scarring, or dense anterior cortical or opaque white cataracts, is a contraindication for the procedure.

"Anything that will give us problems with docking, such as surface irregularity, conjunctival chalasis, unusual orbital anatomy, and excess retropulsion" may also make a patient unsuitable for the femto procedure.

An existing trabeculectomy bleb should be avoided as well because there is concern about bleb damage, Dr. Seibel said. Some manageable concerns include anterior capsular fibrosis, density of the lens nucleus, and lens colors, Dr. Uy said.

"We're not fazed by dark brown cataracts," he said.

In the "not so good candidates" category, Dr. Uy said, are patients with significant corneal opacities. Small ptyergia may result in suction loss. Dr. Uy said surgeons may proceed with caution on black cataracts, maybe performing a capsulotomy and lens fragmentation, but that's it.

"Be prepared to do some extra maneuvers if the orbital anatomy is not very favorable," he said. "In small palpebral fissures, sedation and local block can facilitate application of interface and docking."

Dr. Lane said astigmatic correction "has been an unmet need in cataract surgery, especially as patients expect better refractive outcomes." He added, "Our ability to do that with cataract surgery has certainly been lacking," he said. "The opportunity to do that better is what we're looking for."

He cited a study by Warren Hill, M.D., which showed that 89% of patients have 0.25 D of astigmatism. "The opportunities are great if the laser can deliver on astigmatic correction," he said.

Dr. Kim agreed that demand is increasing. "When we're going to raise the price, we're going to raise the expectation," he said about astigmatic correction performed with the femtosecond platform. "Why do we pay attention to astigmatism? It's because it affects vision. If we don't pay attention to it, those patients are not going to like that."

Currently, of the three ways to correct astigmatism (excimer laser, toric lenses, and corneal incisional surgery), most surgeons use toric lenses, Dr. Kim said. "The excimer laser is extremely effective at treating astigmatism," he said. "Unfortunately, it's a separate surgery."
 Limitations of toric IOLs include the possibility of IOL calculation error and post-op rotation.
"Torics rely on accurate alignment," Dr. Kim said. "Even if you place the lens perfectly on the axis, there have been cases where the lens can rotate post-operatively then you have to go back, inflate the bag, and reposition the lens."

Good alignment is also needed with peripheral corneal relaxing incisions in order to get the best result. The fact that the femtosecond laser is automated is intriguing, Dr. Kim said.
"All of this is automatedthe depth of the incision, the length of the incision," he said. "That's an amazing component to this technology. It's an easy procedure to perform, and it's forgiving. It's repeatable. There's a fairly quick recovery. It's a great technology that can alleviate the astigmatism, but again, it's another surgery."


Day 2 of the ASCRS/EyeWorld Town Hall Meeting on Laser-Assisted Cataract Surgery opened on Saturday, July 16, with a lively discussion on the controversial matters of compliance and Medicare payment surrounding the new technology. This was followed by a panel dealing with questions regarding the cost effectiveness of femtosecond cataract surgeryboth for the patient and the practice. The third session of the day gave physicians who have implemented laser-assisted cataract surgery a chance to share their workflow practices. The day closed with an open discussion on who's operating the laser and related implications.

How do I stay in compliance and still get paid?

ASCRS Government Relations Director Nancey K. McCann discussed Medicare reimbursement realities, carefully laying out the well-defined coverage and payment parameters set up by the U.S. government.
The procedure on a medically necessary cataract, no matter how it is performed, is covered under Medicare. The covered procedure includes making an opening in the eye to permit entrance of the surgical instruments, capsulorrhexis of the anterior capsule, and fragmentation of the lens nucleus. Pre-op, intraoperative, and post-op care is covered, Ms. McCann said.
Ms. McCann emphasized that surgeons cannot charge more for cataract surgery just because they are using a femtosecond laser.
"You cannot bill the patient extra for anything that is part of the covered service," she said. "Medicare doesn't care what you use to do the procedure."
However, non-covered services, such as astigmatism correction, which is also performed by the femtosecond laser, could be billed to the patient.
Long-term Medicare payments will be based on quality, outcomes, and efficiencies.
"We have to look at the long-term reimbursements because the way you are getting paid today is not the way you will be getting paid tomorrow," she said.
Medicare will become a value-based budget neutral payment system by 2017 based on outcomes and efficiencies.
"That means no more money is going to be coming into the system," Ms. McCann said, clarifying that the new system will be one of penalties and bonuses, meaning if one surgeon gets a bonus, another will be penalized in order to keep the system balanced. "There are no floors and ceilings. You're going to be compared to other physicians in your geographical area," she said about future Medicare payment parameters.
Surgeons employing the technology should be cautious when touting the potential benefits of the surgery.
 "I'm very concerned when I hear physicians use words like quicker, safer, easier, and better outcomes, particularly when there isn't any data to back that up."

Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., president, Corcoran Consulting Group, San Bernardino, Calif., gave details about covered and non-covered services. Covered services include the exam or consultation, biometry, K-readings, B-scan, endothelial cell count, the surgery and post-op care, a conventional IOL, facility fee, and anesthesia. Refraction, tests for emmetropia, screening, refractive surgery, IOL upgrade, added facility fee, and expanded post-op care are non-covered services.
"If you decide you want to bill for those things above and beyond (covered services), that's where we get into the murky area," Mr. Corcoran said.
So how do surgeons go about setting up professional fees for laser refractive cataract surgery?
"You need to think of a number you can defend," Mr. Corcoran said.
Controversies and potential trouble will arise if surgeons charge patients extra money to discuss treatment options, use more than one IOL formula, place the corneal incision where it works best, use a femtosecond laser for any part of the cataract surgery, perform services of dubious value, do routine cataract surgery, or circumvent assignment rules.
"You already have professional fees for what you do. They also apply in the context of refractive surgery. Extraordinary or distorted fees are suspect," he said.

Is femtosecond cataract surgery cost effective for the practice and the patient?

Before the second session began, Edward J. Holland, M.D., Cincinnati, moderator, posed a question to the audience: Are you confident patients will pay the fees (for femtosecond cataract surgery)? Currently in the U.S., experts agree only astigmatism correction, which is also performed by the femtosecond laser and not a covered procedure under Medicare, can be billed to the patient.
Sixty-two percent of those who responded said "no," followed by 68% who said they didn't believe the economics would work in their practice.
Stephen S. Lane, M.D., Stillwater, Minn., presented the pros for adopting the technology now, including being the first to have it and being involved in the early developments with regard to how it works, pricing, and workflow.
"I think most of you believe, or you wouldn't be here, that this is something that is going to go forward in the future," he said. "Our group has always been one of those practices that says the best way to predict the future is to create it."

Cons include the cost and the emotion behind the decision, including the transition for staff with regard to changes in workflow, scheduling, and pricing, Dr. Lane said. "It will demand acceptance and buy-in by the MDs and a change in mindset for the program to be successful," he said.
Dr. Lane used a manufacturer calculator to show the audience how to determine financial liability, and he said the number of cataract procedures performed in a practice is important.
"It's very much volume dependent," he said about the decision to adopt femto for cataract technology in his practice, which he shares with 10 other surgeons.
The laser surgery would be used on patients with pre-existing astigmatism.
"The potential patient population that has the greatest impact on helping to pay for this are those patients who have lower levels of astigmatism that you may not have been dealing with in the past, either with toric intraocular lenses or with manual arcuate incisions," Dr. Lane said, adding that money would have to be spent on marketing the new technology.

Stephen G. Phillips, M.D., a solo practitioner in Seattle, said he didn't think that small practices would be able to afford the expensive technology alone.
"One guy alone is going to have trouble doing this," he said. "You are going to have to band together. If you are a cataract surgeon already, team up with a refractive surgeon. Those are natural partnerships. You need to have a refractive mindset, or it will not fly."
Patients are the most important element, Dr. Phillips said, echoing Dr. Lane's assertion that more patients equals better opportunities for success.

Richard R. Lindstrom, M.D., Minneapolis, argued that patients would willingly seek out above excellent refractive results. Currently, astigmatism correction performed by the femto laser, which is not a covered procedure under Medicare, can be billed to the patient. Dr. Lindstrom decried low conversion rates to premium IOLs, adding that correcting astigmatism will help sharpen a premium patient's eyesight. "I think it's because we surgeons aren't up to the task," he said about why conversion rates are so low. "We aren't generating good enough refractive outcomes to generate strong patient word-of-mouth referrals. We need to do significantly better I think, in the end, it's really the patient who is going to make the decision."

Steven G. Safran, M.D., Lawrenceville, N.J., argued that laser-assisted cataract surgery is "not cost effective."
"Ophthalmologists can't absorb the extra costs incurred by this technology," he said. "Even a projected slight decrease in enhancement rate won't come anywhere near paying for this."
The idea that lasers are better is antiquated, Dr. Safran said.
"What about macular degeneration?" he asked. "We used to treat it with a laser and now we treat it with a needle. Patients want what we recommend to them because they trust us to choose what serves their best interests. Patients are not fixated on the laser."
Dr. Safran pointed out that cataract surgery is the most successful procedure in the United States, and the results from both manual and femto surgeries are practically identical.
"I feel like we are trying to fix something that isn't broken and get money out of a system that is," Dr. Safran said. "We need better lenses. That is what is going to drive our conversion rates." "Dead wrong," Dr. Lindstrom countered. "It's not the technology it's our ability to get to plano."

Douglas Koch, M.D., Houston, added, "Any process that takes away the potential for human error deserves a look.
The irony of this whole discussion is the people who are going to use it are the people who do beautiful surgery as it is."
D. Brian Kim, M.D., Dalton, Ga., who spoke from the audience, agreed, and put the question out there: Will newly trained surgeons ever learn how to perform manual surgery or clean up complications that way?
 Dr. Lane cautioned practitioners against being immediate naysayers.
"I think this is a technology that in 10-15 years, everyone is going to be using," he said. "Technology is going to march ahead whether we want it to or not. All surgeons are going to jump in when they feel prepared to do it or when they have the pressures that surround them."

John D. Banja, Ph.D., a medical ethicist in Atlanta, Ga., discussed patient counseling considerations and extolled the virtues of a good informed consent because then the patient is the one who takes on the risks.

Practice flow logistics

Adopting a femtosecond cataract machine will involve a change in patient flow and practice logistics, according to several early adopters of the technology, including two surgeons who use the technology outside of the United States.
Harvey Uy, M.D., Makati, Philippines, spoke about how the addition of femto cataract surgery has changed his clinic flow.
The surgeon explains the procedure, risks, and benefits, while the scheduler discusses the schedule with the patient, he said. To facilitate workflow, "We schedule the more predictable surgeries toward the beginning of the day and the complex cases come at the end of the day."
Dr. Uy's surgical flow involves using two roomsone for the femto laser and one for phacoemulsification. The rooms are located directly across from each other.
"It is easy for one room to communicate with the other," Dr. Uy said, adding that surgeons should think carefully about optimizing efficiency when laying out their new femto workspace.
Kasu Prasad Reddy, M.D., Hyderabad, India, said his clinic is set up currently so that one surgeon performs the femto procedure and another performs phaco. Dr. Lane's current set-up includes four pre-op bays that feed into one OR led by one surgeon. His laser will be placed outside the OR but inside the ASC firewall.
"The patient will be on a mobile chair/bed and will move from the laser bay to the pre-op bay or the OR," he said. Dr. Lindstrom wrapped up the session by encouraging physicians to enlist regulatory and legal consultants to assist them in navigating the decisions involved in where to place the laser.

Who's operating the laser? Implications

In the fourth and final session of the day, panelists and attendees debated potential scenarios for the operation of the femtosecond laser, covering all of the angles: ophthalmologists, technicians, optometrists, and physician's assistants.
The panelists led a conversation about the different scenarios that might be raised when it comes to who would be operating the laser in the future. Mr. Corcoran and Ms. McCann said there isn't licensure in any state that would allow a technician to perform the procedure. Optometrists currently can use some lasers in Kentucky and Oklahoma, but their scope of practice has not been widened to include laser surgery beyond those two states. "We in organized ophthalmology are spending hundreds of thousands of dollars in fighting scope of practice battles across the United States," Ms. McCann said. "Yes, there are two states that allow optometrists to do laser surgery, but at this time, when we're fighting and saying that they do not have the skills or training and should not use the lasers, I obviously would be very concerned if we all of a sudden decided they can do the femtosecond laser surgery."

"This is a distinct ethical issue," Dr. Banja said, "one that boils down to patient safety."

Audience member Mark Cherney, M.D., Melbourne, Australia, added that a surgeon delegating this responsibility might destroy medical heritage created over the centuries.
"We're asking people to trust us to operate on their eyes," Dr. Cherney said. "They have chosen us above all other surgeons to take the responsibility and have that relationship with them. This is important to them. We are not willing to take 6 minutes to go across the corridor to be with them, to look after them? That would be a travesty."


The closing day of the ASCRS/EyeWorld Town Hall Meeting on Laser-Assisted Cataract Surgery, Sunday, July 17, began with mock scenarios set up to pose ethical dilemmas to the panelists and audience, which sparked spirited discussion and debate.

In the first case, a 67-year-old Medicare patient asked for femto with a standard monofocal lens implant. The patient had been told that he has a very shallow anterior chamber where the capsulorhexis would be more challenging than usual. He also has a dense cataract, which could increase the value of using the laser. This patient, though, said he prefers to wear glasses afterward, and he does not need astigmatic correction.

The surgeons discussed whether they would use the femto laser and/ or suggest multifocal IOLs and how they would charge for using the femto in this instance.
"Your cataract procedure has already been paid for, and if you attempt to make the multifocal IOL a camouflage for what has already been paid for, you are on a slippery slope," said Kevin J. Corcoran, C.O.E., C.P.C., F.N.A.O., president, Corcoran Consulting Group, San Bernardino, Calif. Attendee Ravi A. Shah, M.D., Portland, Maine, asked hypothetically whether a surgeon could end up in hot water for not using a technology that may produce better results.
"If you have a femto laser and you're doing a standard phaco case, and you have a problem with that case, would you ever be held accountable when you're asked the question, 'Doctor, you had this complication during the surgery and you had another tool at your disposal that might have been a better choice. Why did you choose not to use that, and did your decision not to use that lead to harm?'" Dr. Shah asked.

"Those questions are at the essence of the ethical conundrum associated with femtosecond laser surgery," said panelist Stephen G. Phillips, M.D., Seattle. At this point, "We do not have a good mechanism for saying this is a medically necessary part of the treatment."
D. Brian Kim, M.D., Dalton, Ga., agreed.
"We need more studies [before we can] say that it's safer and it gives us better results," he said. "Still, this is a tool, just like an iris retractor, Malyugin Ring [MicroSurgical Technology, Redmond, Wash.], or trypan blue. It's up to us to make the decision whether or not we need that tool." Attendee Joseph Calderone Jr., M.D., Cranford, N.J., said the scenario puts doctors in a tough position. "We're going to be trapped now between the costs of providing the standard of care and the ethics of providing it," he said. The discussion then turned to U.S. regulations and the billing restrictions put on surgeons. Edward J. Holland, M.D., Cincinnati, said the answer is political.
"The average ophthalmologist doesn't know his state legislator and doesn't know individuals in Congress," he said. "If we want to change things, we need to get [politically] active. If you talk to the physicians who are now in Congress, they are begging us to get involved and be a part of the process. We can make a difference, but we need to get active like other specialties are."

In another scenario presented to the audience, a 72-year-old patient wants a multifocal lens and also requests the use of the femto laser. The surgeon does not have the laser, but his competitor does.

The surgeons discussed whether the doctor in this case is obligated to refer the patient.
"We need to give [patients] full disclosure that this technology is available," Dr. Kim said. "At this point, it remains to be seen if it is better, but I think we are obligated to tell them if it is."
The question was posed whether surgeons are obligated to tell patients about every new piece of equipment that comes on the market.
"It would be a reasonable thing for you to do, especially if you think you have a technology that is superior and that is going to advance the patient's welfare," said John D. Banja, Ph.D., medical ethicist, Atlanta, Ga. However, "you don't have an ethical obligation to recommend a treatment that's not FDA approved and whose inclusion in the standard of care is debatable."

Stephen S. Lane, M.D., Stillwater, Minn., said patients may be the ones bringing the discussion to the table. "Doctors aren't going to push this thing through, the patients are," he said. Attendees reminded early adopters of the technology of their responsibility to report all results, good and bad. "This could be the Titanic," said Mark Cherney, M.D., Melbourne, Australia. "We want to know if we're on the right vessel. If the captain steering isn't telling us there are icebergs here or there, how are we going to make the right judgment? In the discussion of ethics, there is a responsibility for those people to give us good information."
Harvey Uy, M.D., Makati, Philippines, promised to continue collecting data and to publish his data.

During the entire Town Hall meeting, no one was a more vocal opponent to the femto-for-cataract technology than Steven G. Safran, M.D., Lawrenceville, N.J. Many of the attendees, even those who were in favor of adopting the technology, sang Dr. Safran's praises.
"Dr. Safran has to be congratulated for having the guts to come out here to take on a panel with Dr. Lindstrom," Dr. Cherney said. "[Dr. Safran] is incrediblea good communicator and clear thinker, and for him to take this position was very courageous." Dr. Safran said he feels very passionately that the femto approach yields no better results than a manual procedure. "Honestly, I felt I had a responsibility to do this," he said about being on the panel. "I'm trying to help us avoid making a big mistake. I'm worried about my profession, truly."

Despite Dr. Safran's passionate and sometimes entertaining misgivings about the technology, the sentiment that prevailed was one of excitement. "The pure ethical question is fascinating," said audience member J. Alberto Martinez, M.D., Rockville, Md. "It's exciting technology. When LASIK came out, I didn't jump on it right away. Some of the guys who did jump on it, I watched them move on and do very well. I don't want to wait now. I am more confident that this is the way to go."

Although there were some unanswered questions remaining at the end of the weekend, overall, attendees at the meeting were pleased with the format and the content of the sessions. They especially enjoyed the more intimate size of the meeting and the resulting in-depth interaction among participants.

Editors' note: Dr. Donnenfeld has financial interests with Bausch and Lomb (B&L, Rochester, N.Y.), Abbott Medical Optics (AMO, Santa Ana, Calif.), and LenSx Lasers. Dr. Kim has no financial interests related to his talk. Dr. Koch has financial interests with AMO, Alcon, and OptiMedica (Santa Clara, Calif.). Dr. Lane has financial interests with AMO, Alcon, B&L, and OptiMedica. Dr. Lindstrom has financial interests with AMO, Alcon, and B&L. Dr. Phillips has no financial interests to report. Dr. Reddy has no financial interests related to his talk. Dr. Safran has financial interests with B&L and Heidelberg Engineering (Heidelberg, Germany). Dr. Seibel has financial interests with OptiMedica. Dr. Talamo has financial interests with Alcon, B&L, and OptiMedica. Dr. Uy has financial interests with Alcon and LensAR.

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