As laser technology develops, understanding new equipment is becoming vital.

Femtosecond-assisted laser cataract surgery provides surgeons an exciting new option to potentially improve patient outcomes and safety. With this technology, surgeons can perform many parts of the cataract procedure including the capsulorhexis, corneal incisions and lens nucleus fragmentation with softening. The introduction of this technology has been accompanied by a host of new clinical, logistical and financial challenges for surgeons and ophthalmology practices.

Many surgeons are faced with a key question: Is a femtosecond laser necessary for their practice? After all, skilled surgeons can continue to obtain good results using traditional techniques, with few complications and favorable visual outcomes.

Several important questions arise with regard to the introduction of femto-phaco technology, including:

■ Does this technology truly improve cataract surgery outcomes?■ How does the safety profile compare to traditional phacoemulsification?
■ Are additional complications introduced by using this laser?
■ How can it be logistically incorporated into the practice?
■ Which patients will benefit from using this technology?
■ What is the best business model to finance the laser and ensure a profit for the practice?

This article will provide a brief overview of femto-phaco (laser-assisted cataract surgery) and will discuss the intricacies of incorporating a laser into one’s practice.

What Can the Laser Do?

The femtosecond laser’s functions in cataract surgery include: capsulorhexis creation, lens nucleus fragmentation or softening, and construction of corneal incisions.

■ Capsulorhexis. Some surgeons recommend a laser-created capsulorhexis to obtain a more predictable effective lens position for the IOL. A round and symmetric capsulorhexis with the anterior lens capsule overlapping the optic’s edge is optimal for accurate postoperative IOL centration. This is particularly important for multifocal IOLs, where a small degree of decentration can induce a significant visual disturbance.

■ Nucleus fragmentation. Using the femtosecond laser, the surgeon easily can divide the nucleus into fragments within seconds. The femtosecond laser then delivers additional energy to subdivide the fragments, essentially softening the lens so that the phaco probe can aspirate the lens with the use of less ultrasound energy.

■ Corneal incisions. Two types of incisions can be made with the laser: 1. the primary wound and paracentesis, and 2. limbal relaxing incisions for astigmatic correction.

1. Primary wound and paracentesis: In a matter of seconds, the laser can create precise corneal wounds that can then be opened with a blunt instrument at the initiation of phacoemulsification.

2. Astigmatic correction. Outcomes of manual arcuate incisions have traditionally been difficult to predict. The femtosecond laser allows the surgeon to more precisely create incisions at a particular depth, position and arc length. The surgeon can then titrate the astigmatic relaxing effect postoperatively by selectively opening varying degrees of the incision based on postoperative refraction and corneal topography.

The laser generally can correct up to about 1.5 D of astigmatism with significant accuracy; however, for higher levels of astigmatic correction, a toric lens is still indicated.

■ Premium lenses. Surgeons have also found the femtosecond laser useful for patients receiving premium lenses. These are typically more demanding, younger patients, many of whom may be pursuing refractive lens exchange for presbyopia. Extreme precision and accurate IOL centration is crucial to optimize outcomes. Achieving perfect centration and rapid visual recovery is critical in this subgroup of patients who have high expectations after paying extra for a lens upgrade.

Some observers view premium lenses as crucial to the ultimate success of femto-phaco surgery. Since surgeons are unable to charge for the laser itself, the cost is generally bundled with the purchase of a premium lens or with the correction of astigmatism.

Getting Set Up

There are four femtosecond laser platforms available for cataract surgery in the United States. If a practice is considering introducing this technology, it is recommended that you visit a practice that has already successfully integrated a laser into their practice. The individual laser companies are usually very helpful in facilitating such site visits. Particular attention should be paid to ensuring adequate support staff so that efficiency is maintained. Of course, there is a learning curve for the surgeon as well as the surgical center and OR staff. These cases will initially require more time; but, surgical teams typically ramp up relatively quickly and make the necessary adjustments to accommodate this new laser technology.

There are two basic models for laser placement: laser in the OR and laser out of the OR. Most practices have the laser located in a surgical suite outside of the OR. Many practices actually have a second surgeon performing the laser portion of the procedure. In this way, the phaco surgeon never needs to leave the OR and can maintain a rapid flow of patients throughout the OR day. The wounds have been shown to be stable for several hours after the laser portion of the procedure, but the pupil size may progressively decrease, so it is generally recommended that the two portions of the procedure be performed in relatively rapid succession (usually within 30 minutes).

Other surgeons prefer to have the laser and phaco machine in the same OR to minimize patient transport. Much of this decision depends on spatial considerations at each individual site.

Given the laser’s cost, surgery center staff must keep a close eye on finances and surgical efficiency. Frequently, multiple surgeons will share a common laser in attempt to defray costs. Additionally, some companies now have mobile units that can be brought to a surgeon periodically, based on demand.

Clinical Challenges

Ophthalmic technology is in a constant state of evolution. Hence, each ophthalmologist is faced with the challenge of climbing the learning curve if they choose to adopt this new technology. Fortunately, the learning curve associated with femtosecond-assisted cataract surgery is relatively short in most cases. Surgeons must alter their cataract surgery technique to adapt to the new procedure. In addition to learning the docking maneuver, they must learn to interpret the OCT images used by their particular laser platform to ensure accurate laser application and patient safety. They must also alter their phaco technique to accommodate the changes in behavior of the intraocular structures (capsule, lens nucleus, and cortex) following application of laser energy.

The Cost Factor

Is this technology truly worthy of this cost differential? A similar price discrepancy was debated when the femtosecond laser was introduced in LASIK surgery. Until clearly superior outcomes can be demonstrated with the femtosecond laser, this controversy will remain intensely debated.

In the past two years since the approval of the first femtosecond laser platform for cataract surgery, both hardware and software have dramatically improved. With surgeon feedback, the laser companies have been continuously modifying this technology to better suit patients, surgeons and staff.

No matter what technology is used to make a corneal incision, the reimbursement is the same. There is no additional reimbursement for cataract surgeries performed with a laser. Astigmatism correction is the only part of the femto-phaco procedure that can be billed separately from cataract surgery. So how do you justify the cost of a femtosecond laser?

The initial price tag may be overwhelming, however if the cost is shared amongst multiple surgeons in a particular practice or vicinity, this may make the acquisition of a laser more feasible. Solo surgeons may find it more practical to use a mobile unit once a month if their volume permits. Alternatively, community doctors may wish to partner with their local academic institution, which may more easily support this technology financially.

Once you have decided to obtain a femtosecond laser, you should evaluate its yearly costs. The purchase price (approximately $500,000) may not be the biggest expense. The costliest component over five years is most likely per-use click fees and yearly service contracts (typically ranging from $40,000 to $50,000 per year). Fortunately, companies may be willing to negotiate these costs in order to place their laser instead of their competitor’s product.

A typical click fee is about $500 (ranging from about $350 to $850, depending on the laser contract), which calls for charging the patient between $1,000 to $1700. For patients receiving multifocal or accommodating IOLs, prices typically range from $2000-$3500 per eye. Don’t be quick to pre-select patients: It is important that we offer this technology to all patients who are appropriate candidates. At times, you may be surprised at who may be willing to pay for the upgrade in technology.

A New Wave

The femtosecond laser’s role in U.S. cataract surgery is projected to rapidly increase, according to the 2013 Laser Cataract Survey (SM2 Strategic). As of the first quarter of 2013, laser cataract surgery accounted for about 2.3% of cataract surgery performed in the U.S. With the introduction of four competing laser platforms, each with constantly expanding approvals for more aspects of the procedure, the competition spurs ingenuity and rapid product development. The last two years simply reflect the infancy of an industry with tremendous potential to alter the future of cataract surgery. OP

Kendall Donaldson, MD, MS is an Associate Professor of Ophthalmology in Corneal/External Disease/Refractive Surgery at the Bascom Palmer Eye Institute in Miami, Florida.