February 2019


Refractive roundtable
Part 2: Does femtosecond laser-assisted cataract surgery add value to a premium practice?

Dr. Vukich

Dr. Thompson

Dr. Zaldivar

Dr. Williamson

Dr. Waring

Dr. Dell

Dr. Clinch

Dr. Nehls


The conclusion of a discussion among leaders in refractive surgery from the 2018 ASCRS•ASOA Annual Meeting

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 femto laser-assisted cataract surgery adds value to a premium practice. The participants were Roger Zaldivar, MD, 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. This is an edited transcript of the second part of the discussion. The first half appeared in the January 2019 issue of EyeWorld.

Dr. Vukich: Are there any tips you can share on achieving efficiency with the use of the femtosecond laser in your practice?

Dr. Nehls: I think it is ideal to have a partner assist in femto cases, the “shooter.” It would slow a surgeon down to be doing femto surgery for the duration of all cases. In my academic setting, once our fellow is trained, that’s who does the femto cases while I am in the OR removing cataracts. Overall, my efficiency is the same or a little better.

Dr. Vukich: Where do you keep your laser? Is it in your OR or in a separate room?

Dr. Nehls: It’s in what used to be a preop room, right next to the OR.

Dr. Williamson: We have a laser suite adjacent to our OR and that’s where my shooter is. He does all of my monofocals with astigmatism correction and I do the advanced technology IOLs.

Dr. Zaldivar: There is a timing issue here because if you wait awhile after the procedure to do the surgery, the pupil sometimes starts getting smaller. There is a perfect timing and you have to finish from the prior procedure and get to the operating room. Another thing that we improved is that we change a lot of the parameters. Now we are only doing the capsulotomy with the cylinder inside, and that improved much of the reaction of the pupil.

Dr. Dell: As these devices become better, smaller, and faster, and it becomes possible for them to live in the OR entirely, how does that reconcile with the notion that a second shooter in a second location is the ideal state?

Dr. Nehls: You may not need that.

Dr. Dell: Right, if you had it integrated into your phaco machine and microscope and it was quick and easy, and you could do it right there. For those who don’t have a fellow doing their cases, there is a cost associated with having a dedicated second surgeon doing cases during the day. Basically two people to do one person’s job now. How do you reconcile what seem to be competing forces?

Dr. Thompson: You bring up a good point. I think if femto can evolve to that, we’ll see femto use increase. Right now, femto use has plateaued and people are discussing why. For me, early on, I found great value in it. I was fine taking the extra time, and it taught me so much about the well-rounded capsulotomy and what it did for my refractive outcomes. But when the Chang and Waring paper came out on the Purkinje method of centering the capsulotomy with the subject- fixated coaxially sighted corneal light reflex and I started using that in my monofocal patients with an optical zone marker with the patient fixating, I was getting a higher rate of 360 degrees of capsular overlap manually.1 I started to wonder about the value proposition of continuing to do femto. Then I started using the Zepto (Mynosys Cellular Devices, Fremont, California) method with the Purkinje method and I also got nice capsular overlap at a higher rate than manual.2 I think if femto can move back into the OR and with OCT guidance we get a high degree of 360 degree overlap, we’ll see its use increase.

Dr. Vukich: That raises a good question. Femtosecond lasers do four things. They create an incision, create limbal relaxing incisions, create a capsulotomy, and can soften the lens. Which of those features do you think adds the greatest value when you use those for patients?

Dr. Waring: I would rank it in terms of capsulotomy, pre-chopping/softening, then LRI. Another thing that it brings to the table is image guidance. We now do 90% of our cases with femto, so I’m looking before I walk into the OR to see exactly what we’re dealing with and I get a lot of information from doing that. Is it absolutely necessary? No, but do I think it makes me better equipped and understand the patient’s eye better? Yes. We’ve gone on to analyze the biometrics of this and we’re learning a lot that’s challenging the way we think on how eyes behave.

Dr. Clinch: When you ask to prioritize, I think it does an injustice. To me, it is the fact that it has all of these attributes that makes femtosecond cataract surgery superior. In some patients, the phacolysis is the main advantage; for others, it is the precision of the capsulotomy. This is especially true with toric IOLs where capsule overlap is critical. For diffractive IOLs, the ability to place accurate corneal incisions to minimize astigmatism improves the range of visual function. I find in different patients, it has different attributes and that’s why we use a femtosecond laser on the vast majority of our premium patients.

Dr. Vukich: For certain patients we have this package of options and we represent that the laser will be used, but occasionally we can’t do these laser components of the surgery. How do you discuss that with the patient?

Dr. Waring: We treat this a lot like LASIK and PRK. If we have an orbital anatomy that may not lend itself well to a coupling device and a patient interface, we will usually pick up on that in the exam lane and we’ll document that we may not be able to successfully do the laser. Then we’ll always remind them as they’re on the table that I’ll give it three tries, we’ve got a lot of tricks we can utilize, but if we can’t do it, we’re going to do it like we always did without laser and they’re going to be fine.

Dr. Nehls: I think it is very rare though that you can’t get a patient to dock through the entire treatment. The docking systems have improved with some steeper fits and flatter fits for the corneal surface.

Dr. Williamson: I haven’t had one patient in the past 18 months that I’ve been using this that I haven’t at least been able to do part of the procedure on. What’s good about the laser that we use is you can turn different parts off. If the pupil is too small, I won’t be performing the capsulotomy, but I’ll be able to do some segmentation, I’ll be able to treat the astigmatism.

Dr. Clinch: Patients don’t come to a surgeon specifically because they utilize a laser. Patients make their choice based on confidence and trust. I counsel patients that we’re going to try to utilize all available technologies; however, it doesn’t necessarily mean that we can use every option in each case.

Dr. Vukich: There has been a leveling off of the number of FLACS procedures that are being performed. Practices are doing more but in general the number of placements of new machines has leveled off or even started to slightly decline. For those who are active users and are seeing great value in the practice, I wonder what you might attribute that to and how that might turn around?

Dr. Clinch: It is a challenge to provide premium cataract surgery. It requires careful review of every aspect of your practice infrastructure. Some doctors are reluctant to move toward a laser platform because they are uncomfortable with their refractive outcomes. At times, all of us have been humbled by refractive outliers. As surgeons become more comfortable with newer IOL calculation formulas and can reliably deliver a better product, there will be greater utilization of femtosecond technology to fine tune the process.

Dr. Nehls: I think it will also change in the next 5–10 years as trainees come out of their programs and are using it because they trained with it and like it. I think that is going to change the use of FLACS.

Dr. Thompson: As we come to the end of our discussion, would you like to share any parting comments?

Dr. Williamson: I wasn’t practicing during the days of microkeratome and certainly not extracap, but analogies can be made to when we went from extracap to phaco or microkeratome LASIK to femto LASIK in the sense that the data went from being underwhelming to good to overwhelming. I think that as the technology improves and as surgeons improve and learn how to use this, femto cataract may follow a similar trajectory, but for the time being one thing that I would say is to focus on what the technology does, not what it doesn’t do. If safety and outcomes are controversial, which I think is reasonable, what I focus on is predictability, accuracy, reproducibility. If I can automate the steps of the procedure, I think that’s better for my patient, and that’s why I do it.

Dr. Zaldivar: We were skeptical at the beginning so we used it a couple of times. We weren’t convinced and we didn’t adopt it as we should have 100%. The technology has evolved and now it’s much more predictable, it’s faster, it’s better, and now we are ready and we are happy with how we are using it, which is in around 20% of our patients. I think it’s going to grow a lot.

Dr. Waring: I’m going to summarize the point about how we prioritize the benefits and the uniform capsular overlap over the optic. It is well published in the peer-reviewed literature that tilt and decentration can matter and if you can minimize that variable alone, that’s big. Do you need a femtosecond laser to do it? No, we have other technologies, however, the whole package is so compelling, we think it makes sense to provide this to as many of our patients who are willing to have it, and that’s almost all of them. We think it makes a difference because we’re addressing everyone’s focus, to get back to our outcome-driven ideology.

Dr. Dell: I think that each of us should be selecting the pieces of technology that we think will allow us to deliver the result that we want for our patients. It’s rare that this remains static. It constantly evolves, and we’re all striving to search for those best technologies, and we will continue to do that.

Dr. Clinch: As the first laser cataract surgeon in our area, I have always counseled patients that standard cataract surgery is a good procedure. You can achieve a phenomenal outcome without a laser. What I try to explain to my patients is that no matter what they choose, they should do well. While my conversion rate is approximately 80%, it could actually be higher. I counsel specific patients who desire laser surgery that a laser is not necessary for their case. I think we do a disservice when we make everyone feel compelled to use any type of technology.

Dr. Nehls: I think the precision is amazing. It’s relatively new technology. It’s certainly going to undergo new developments, incorporation into the OR, better speed, easier docking, all of that will come down the road, and I think it’s going to be a technology that will be how we do cataract surgery for most of our patients in the future.

Dr. Thompson: I approach cataract surgery as a refractive surgeon, and we’re identifying cataracts at younger ages, so the lens softening aspect, in my patient population, isn’t as powerful anymore. I like having access to femto in my practice, but I think as surgeons we should go into all of our surgeries with what brings us the most confidence for that situation. I’m glad we have all of these technology options.

Dr. Vukich: I’d like to thank all the members of this panel. It has been an excellent roundtable on what I think is an important topic and that is how do we integrate technology into our practice, the continuous reassessment of how the technology adds value, and how we continue to look for the best way to treat our patients.


1. Chang DH, Waring GO. The subject-fixated coaxially sighted corneal light reflex: a clinical marker for centration of refractive treatments and devices. Am J Ophthalmol. 2014; 158:863–74.
2. Thompson V. Streamlined method for anchoring cataract surgery and intraocular lens centration on the patient’s visual axis. J Cataract Refract Surg. 2018;44:528–533.

Editors’ note: Dr. Clinch has financial interests with Johnson & Johnson Vision (Santa Ana, California). Dr. Dell has financial interests with Bausch + Lomb (Bridgewater, New Jersey) and Johnson & Johnson Vision. Dr. Thompson has financial interests with Alcon (Fort Worth, Texas), Johnson & Johnson Vision, and Mynosys Cellular Devices (Fremont, California). Dr. Williamson has financial interests with Alcon, Bausch + Lomb, and Johnson & Johnson Vision. Dr. Nehls, Dr. Vukich, 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

Part 2: Does femtosecond laser-assisted cataract surgery add value to a premium practice? Part 2: Does femtosecond laser-assisted cataract surgery add value to a premium practice?
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