January 2019


Refractive roundtable
Does femtosecond laser-assisted cataract surgery add value to a premium practice?

Dr. Nehls and Dr. Thompson at the roundtable

Dr. Zaldivar and Dr. Williamson

Dr. Waring

Dr. Vukich

Dr. Dell

Dr. Zaldivar
Source (all): ASCRS

A roundtable from the 2018 ASCRS•ASOA Annual Meeting with leaders in refractive surgery

On April 15, 2018, during the 2018 ASCRS•ASOA Annual Meeting, John Vukich, MD, surgical director, Davis Duehr Dean Centre for Refractive Surgery, Madison, Wisconsin, and Vance Thompson, MD, Vance Thompson, Vision Sioux Falls, South Dakota, moderated a discussion on whether femtosecond laser-assisted cataract surgery adds value to a premium practice. The participants were Roger Zaldivar, MD, MSc, MBA, Instituto Zaldivar, Mendoza, Argentina, Blake Williamson, MD, Williamson Eye Center, Baton Rouge, Louisiana, George Waring, MD, Waring Vision Institute, Mt. Pleasant, South Carolina, Steven Dell, MD, Dell Laser Consultants, Austin, Texas, Thomas Clinch, MD, Eye Doctors of Washington, Chevy Chase, Maryland, and Sarah Nehls, MD, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin. The following is an edited transcript of the first part of the discussion.

Dr. Vukich: Thank you very much for attending the joint EyeWorld/ASCRS Refractive Surgery Clinical Committee roundtable. This evening we’re going to discuss whether femtosecond laser-assisted cataract surgery adds value to a premium practice.

Dr. Thompson: Let’s start with everyone briefly introducing their experiences with femtosecond laser-assisted cataract surgery.

Dr. Zaldivar: We were one of the early adopters of this technology. At the beginning we were disappointed because the results weren’t as we expected. Interestingly, this year we have returned, and we are happy with the results. We have found the place in our practice, how to fit it in, and are starting to use it on a regular basis.

Dr. Williamson: I’m probably the newest to this technology. We’ve had it for about 18 months now. We do about 60% of our cases with it and like it, have been happy with the experience.

Dr. Waring: We were relatively early adopters of femtosecond technology for lens surgery, beginning in 2012. I’ve had a wonderful experience, it has rapidly grown adoption in our practice, and currently we’re at about 90% use for the femtosecond laser in cataract surgery.

Dr. Dell: I started performing femtosecond cataract surgery in 2010, and I’ve used two platforms.

Dr. Clinch: We were early adopters in 2011. We’ve used two different platforms. I think there has been a paradigm shift among the platforms, and I’ve done approximately 3,000–4,000 cases.

Dr. Nehls: We’ve had the femtosecond laser for 2 years. Twenty-five percent of my cases are done with femtosecond laser-assisted cataract surgery (FLACS). I am also training our fellow and residents to do FLACS.

Dr. Thompson: I was an early adopter of femto and was involved in the research. I have used it since 2010 but then as of late it has been decreasing.

Dr. Vukich: I was involved in some of the early clinical research and some of the early development of the femtosecond laser platform. We do not currently use that technology in our practice, and I’m interested to explore where the value is and how this might benefit or if this is a segment that we can expect to grow or perhaps level off. I think we have a lot of interest and there is certainly a lot of experience in the room here.

Dr. Thompson: To start out, we all want to do our best in patient education, we all have our different styles. One philosophy is to educate more on vision benefits. The other is to dive into some of the details of the technology that is available. Then there is a hybrid. If we could start the discussion with the question, “Is the femtosecond laser part of your patient education?”

Dr. Williamson: With every single patient who comes in for a cataract evaluation, the last thing my technician does before they leave the room is hand patients a tablet with a movie we made about the femtosecond laser that we use, with animations and things like that, but also with each of our surgeons saying what they like about it. It’s about 8 minutes long and very thorough. After that I come into the room and it makes the conversation easier.

Dr. Zaldivar: If we consider this is better for the patient and we truly believe it, I will try to do it in all of my patients and don’t give an option. My commitment is to do the best that I can with each patient. The patient pays exactly the same whether we are doing FLACS or not.

Dr. Nehls: We predominantly focus patient education to promote the refractive lenses, and virtually all of the patients who have refractive lens surgery go on to have femtosecond laser-assisted surgery. We have some patients who are candidates for femtosecond surgery for smaller amounts of astigmatism and if they would benefit from an LRI then we bring up the laser technology. Our focus is not so much about the femtosecond assisted surgery; that seems to be more easily adopted and understood by the patients. It’s more about the lens choices.

Dr. Clinch: We think it’s part of the comprehensive education process. We think every patient, regardless if they are going to have a refractive lens procedure or even if someone comes in with macular degeneration, should know all the options, so we try to start before the patient comes to our office. They are directed to our website to learn about cataract surgery. Then every patient is educated about femto as part of a refractive package, and we try not to dwell on safety as much as we use an acronym—GAP. It makes the surgery more gentle, accurate, and predictable. We try to use that acronym because we have five cataract surgeons and about 20 technicians, so one of the fears is not giving a consistent message among surgeons. Trying to have a consistent message and education on all processes is helpful.

Dr. Vukich: Do you discuss the results and outcomes, expectations with your patients, and how do you fit femtosecond laser into that conversation? What do you tell patients they might expect to gain as a result of choosing that modality?

Dr. Waring: We take patients on a digital tour of their eye and explain how we have advanced options for cataract removal, and we do this in a gentle fashion with light, with lasers.

Dr. Dell: I have a little different approach, which is I tend to stress visual outcomes entirely. Whatever technology I think I need to use to obtain that outcome, that’s what I should be using. I think that if a patient opts for a presbyopia-correcting IOL but for some reason doesn’t want the laser, that patient, in my mind, shouldn’t be paying something different from a patient who does want it. If you think the laser, or a capsular dye, or some other technology is the best way to achieve your goals, you should incorporate those technologies in that particular case, and it should be independent of the finances. I’ve always been uncomfortable with this decoupling of results and technology. I think you should deliver an outcome. You ask the patient to compensate you for that outcome, and I don’t think that the technology you choose to deliver that outcome should factor into it.

Dr. Thompson: I educate patients on their vision options. We typically talk traditional cataract surgery and wearing bifocals vs. premium and restoring the reading range also. We talk about the distances they want to use their vision for, and we don’t necessarily talk about the technologies it takes to get there. I’m getting to know them and helping them with their vision decision, and whether or not I use a manual capsulotomy or an automated capsulotomy, Zepto (Mynosys Cellular Devices, Fremont, California), or femto, I’m using what I think is best to achieve that visual outcome for that situation. In my practice the use of femto technology has declined dramatically. For patients choosing presbyopia correcting implants the majority of my automated capsulotomies are now performed with the Zepto technology.
Do you think the value of the femtosecond laser is there when you compare what it does to the price of what the system is?

Dr. Zaldivar: I think that’s the most critical question because the economics are tough with femtosecond platforms. Nowadays I’m finally getting to that sweet spot where I am more comfortable, and that’s because the platform I’m using includes the possibility to do flaps. I’m positively surprised with the flaps that I’m getting, and I’m using it with most of our flaps today. I’m using it in LASIK and phaco. I’m comfortable with the economics of this, and I think that’s important.

Dr. Dell: There are many physicians whose positions I respect who think that the femto clearly adds value in their hands, and in certain cases I can understand why that is the case. But if I envision a scenario where a patient had bilateral cataract surgery and it was done under general anesthesia and both eyes got the same IOL, would the patient be able to tell a month postop which eye had been done with femto and which eye had not been done with femto? If you made that same comparison with a multifocal and a monofocal, the patient would know immediately. The value proposition to the patient is clear with a presbyopia correcting IOL, but with femto it’s in the lap of the surgeon as to whether or not it makes the task more easily accomplished.

Dr. Clinch: We try to drive an outcome to our patient, whether it be distance acuity or a correction for reading or presbyopia. I live in Washington, D.C., which is a very technical part of the world and where people are very outcomes driven. I try to use all of the different technologies. I will use a laser on all of my patients. My thought is no matter what you do, you’re not always going to have 100% success. For me, having used every modality possible, I can look my patient in the eye and say I did everything possible to get you where you are. We’ve used advanced formulas, lasers, intraoperative aberrometry, and the lens with the best optics for their visual life. To me, it’s more of offering a package of goods. Because we do a fairly high volume at our surgery center, it reaches a point where it’s not super expensive, in the long term, to use the laser, because our center does between 2,000–3,000 per year. It has kept the cost economical for us to be able to do that and not have a huge incremental cost to using the laser.

Dr. Williamson: We have a similar experience. We’re a high-volume center and depending on how many cases you are doing with the femtosecond laser, it can add tremendous value. Last year, we were up 25% in terms of our revenue from our cataract program, so it adds value monetarily. But I also think it adds value to the patient and to the surgeon. For the patient, I think the value is they see better quicker. Day 1 the vision is crisper than in my manual cases, but they have more of a ‘wow’ factor earlier. As to them understanding the value, they equate the laser with precision. As much as we talk about it, as much controversy as there is, they have already decided they want that precision of the laser. My patients aren’t OK with a less precise procedure even if it gives them safe, good outcomes. I think precision does matter. The value for the surgeon, for me, doing a lot of cases, is it’s nice having a shooter system like what we use, to have half the case done before you get into the OR. It adds efficiency. People talk about efficiency and how femto slows you down. It does if you allow it to, but you can also use it to speed you up and add more cases per hour, and that’s what we’ve been able to do by employing a second surgeon as a shooter.

Editors’ note: Dr. Dell has financial interests with Bausch + Lomb (Bridgewater, New Jersey) and Johnson & Johnson Vision (Santa Ana, California). Dr. Thompson has financial interests with Alcon (Fort Worth, Texas), Johnson & Johnson Vision, and Carl Zeiss Meditec (Jena, Germany). Dr. Vukich has financial interests with Johnson & Johnson Vision. Dr. Williamson has financial interests with Alcon, Bausch + Lomb, and Johnson & Johnson Vision. Dr. Nehls, Dr. Waring, and Dr. Zaldivar have no financial interests related to their comments.

Contact information

: tclinch@edow.com
Dell: steven@dellmd.com
Nehls: nehls@wisc.edu
Thompson: vance.thompson@vancethompsonvision.com
Vukich: javukich@gmail.com
Waring: gwaring@waringvision.com
Williamson: blakewilliamson@weceye.com
Zaldivar: zaldivarroger@gmail.com

Does femtosecond laser-assisted cataract surgery add value to a premium practice? Does femtosecond laser-assisted cataract surgery add value to a premium practice?
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