Image-guided femtosecond laser cataract surgery, the latest buzz in ophthalmology, promises to help eye surgeons dramatically improve refractive outcomes. But at what price? Will patients pay $3,000 out-of-pocket per eye for blade-free refractive surgery? Will surgeons pay a per-procedure fee, widely rumored to be $450, to use the lasers?

Femtosecond lasers overcome the limitations of manual cataract surgery, including imaging of the front of the eye, cataract incision, capsulorhexis, cataract segmentation and softening, and limbal-relaxing incisions, says William W. Culbertson, MD, professor of ophthalmology at the Bascom Palmer Eye Institute in Miami, Fla., and consultant to OptiMedica, producer of 1 of the 3 laser platforms seeking FDA approval (see "Your Laser Platform Options" on page 60). Other reported benefits:

• Standardized results. No 2 incisions made during manual cataract surgery are alike, says Mark Packer, MD, FACS, who splits time between his duties as a clinical associate professor of ophthalmology at Oregon Health & Sciences University in Portland and a private practice in Eugene. He's also on the advisory board of LensAR, a laser platform seeking FDA approval. That variability increases complication risks and accounts for variability in case outcomes. Dr. Packer believes laser technology will standardize the depth and arc lengths of incisions to increase predictability in the size, shape and diameter of the capsulorhexis, which is critical to the ultimate success of refractive cataract surgery.
• Less collateral damage. Softening the cataractous lens with a laser means that less ultrasound energy will be required during phacomulsification, which minimizes morbidities and damage to intraocular structures, says Dr. Packer. Dr. Culbertson says OptiMedica's Catalys allows for precise treatment at low energy levels. In clinical trials, the Catalys cut the lens nucleus at 0.5mm from the posterior capsule, meaning it achieved almost complete dissection of the lens. Chopping the lens into little pieces makes phacomulsification aspiration that much easier, says Dr. Culbertson, adding, "If we use 40% less phaco energy to aspirate hard lens material, we'll see less post-op inflammation, less damage to the back of the cornea and less time in the OR with the eye open to the elements."
• Improved IOL placement. Femtosecond laser platforms will dovetail nicely with the premium IOL market, says Dr. Culbertson, because the technology "will eventually enable the creation of some intraocular lens implants that we haven't even conceived of yet." He cites his own research that compared the shape and accuracy of manually performed capsulorhexes and laser capsulotomies. According to Dr. Culbertson, the laser capsulotomies were all a consistent size and within 100 microns of the intended positions.

That accuracy and reproducibility means surgeons can simply program the laser software to design capsulotomies that perfectly accommodate the size and shape of the intended IOL implant. By customizing capsulotomies, surgeons can center IOLs in the eye with greater consistency, which leads to more predicable and effective refractive outcomes, says Richard Lindstrom, MD, consultant to LenSx — the only system that's currently available in the United States — and founder of Minnesota Eye Consultants in Bloomington.

Ophthalmic surgeon Zoltan Nagy, MD, a professor at Semmelweis University in Budapest, Hungary, says laser platforms can liquefy the cataractous lens, create a perfectly centered and sized refractive capsulotomy, and create self-sealing corneal incisions with perfect dimension and architecture. Lasers can also create precise corneal incisions to solve pre-existing astigmatism, he says, which converts "a very manual, multi-step, multi-tool procedure to an integrated, laser-precise but surgeon-controlled procedure."

In a widely publicized study, Dr. Nagy and colleagues compared the outcomes of 60 laser capsulotomies performed with the LenSx against 60 manual capsulorhexis procedures. He found that using the laser resulted in perfect centration in all cases, without any radial tears or adverse events. His data showed that all laser capsulotomies were within 0.25mm of the intended diameter, compared to only 10% of the manual capsulorhexes.

So what's the catch?
"Of course, the technology isn't free," cautions Dr. Packer. He believes femtosecond lasers are the future of cataract surgery and that refractive surgeons who are already implanting premium IOLs will quickly adopt them —as long as patients are willing to incur the additional expense, similar to how you pass on the cost of a premium lens upgrade to patients willing to pay an incremental fee for enhanced refractive outcomes for which Medicare and most third-party payors are not yet willing to reimburse.

Dr. Lindstrom agrees that widespread use of the laser platforms will demand a "shared responsibility" from patients in order for facilities to justify the technology's expense, which he believes will match or slightly exceed the $300,000 to $350,000 price tag of femtosecond lasers used for LASIK surgery.

How much more will patients have to pay out of pocket for the technology that's said to provide better, safer outcomes? That's yet to be determined, but Dr. Packer believes the upgrade to laser cataract surgery could cost patients around $3,000 per eye. The future of laser cataract surgery will depend on convincing patients to spend a little extra to meet their post-op vision goals.

Dr. Culbertson believes demand for the technology will increase over the next 2 or 3 years because patients have an "intuitive understanding that laser treatment is more precise and dependable than surgery done by hand." Widespread acceptance might also be driven by competition. "Word will spread if a surgeon acquires a laser, which could set him apart as a 'high-tech doc,'" says Dr. Culbertson. "A competing surgeon who does wonderful work without the technology, and believes he performs surgery just as well by hand, might be looked at as someone who's holding on to outmoded ideas." Many good surgeons might not benefit greatly from these machines, he says, "but they could serve as a marketing bonus for the docs who have them."