The next big thing?

Will femtosecond lasers be routine in cataract surgery in 10 years?

Is the femtosecond laser the next big thing in cataract surgery? Multiple studies presented at the recent  AAO annual conference suggest this could be the case, but some question the economic feasibility of this approach.

One study was a 50-patient series using the Alcon LensX system presented by Stephen G Slade MD, Houston, Texas, US. He achieved a perfectly centrated, precisely-sized capsulorhexis in every case, with reduced phaco power, and was able to incorporate astigmatism correction with limbal relaxing incisions at the same time.

The result was improved visual outcomes, with the standard deviation of achieved correction from target dropping to 0.4 D from a background rate of 0.6 D. Dr Slade also saw reductions in endothelial loss using the femtosecond laser. “We use it routinely on our premium lens cases and to treat astigmatism,†he said. And he thinks that within a decade most other surgeons will too.

“Why? Two words – effectiveness and safety,†Dr Slade said.

And the baby-boom generation will demand it, he added. Using FDA approval data he showed that on average LASIK trials generated better visual outcomes than IOL trials.“We are not giving cataract patients the same results that they are used to with refractive procedures.†Not everyone agreed.

“Will it happen? Well, here’s my answer – Not in my ASC [ambulatory surgery centre],†said William Rich MD, Fairfax, Virginia, US. The cost will be prohibitive, and the government, which covers most patients over age 65 in the US, won’t pay for it, added Dr Rich, who is medical director for healthcare policy for the AAO.

By giving surgeons a fixed payment for cataract surgery, the government puts surgeons at risk for the cost of technology.

“We get paid the same if we use a bent 20-gauge needle or a Fugo blade for $2,000,†Dr Rich said.

Unlike premium IOLs, which Medicare considers an extra, routine cataract extraction is considered a medically necessary covered procedure. Therefore, Dr Rich believes the programme will not pay extra for it. If femtosecond lasers reduce surgery times, Medicare may even reduce payments, Dr Rich said.

Under current rules, surgeons also would have to quit the Medicare program for two years to charge patients directly for any covered service, Dr Rich pointed out. This would not be practical because it would require ophthalmologists to bill patients directly for the entire cost of every service, instead of receiving the payment directly from the government. He also believes that few patients would pay the entire cost of cataract surgery, plus the facility cost, plus the $500 or $600 extra needed to cover the cost of the femtosecond laser.

“In the end the femto laser is a great device in search of a viable business plan. I don’t see one,†Dr Rich said.
Dr Slade disagreed. “The market will decide. PRK and LASIK are both good procedures, but people wanted LASIK more, so we do LASIK. People wanted femto flaps more than a steel blade, so we do femto flaps, and I bet you they will want femto cataract surgery.â€

At the end of the session the audience was deadlocked – 50 per cent each agreed and disagreed that femto cataract surgery would be routine in a decade.

Douglas Koch MD, Houston, Texas, US, also addressed the issue in the Kelman lecture, “The Quest for the Perfect Cataract Surgical Outcome: 10 predictions for the next 10 years.†In fact, the integration of femtosecond laser technology into routine clinical practice was his first prediction.

“It will open new doors. We haven’t even scratched the surface yet,†Dr Koch said. He also noted that femto lasers can cut a capsulorhexis precisely and predictably every time, and that the implications of perfecting even this one step in the procedure are unknown. “We don’t even know what the best capsulorhexis is or where we want it.â€

Dr Koch acknowledged that the expense of transitioning to femto technology and providing it broadly to patients would be high. He even suggested that the greater automation of surgery combined with a shortage of ophthalmologists could create pressure to allow optometrists or other non-physicians to get involved. “The choices we make will have consequences. You can see how things could go. On the other hand, won’t our patients want the best technology? And won’t we want to give it to them?â€