INSIDE INFORMATION For John Berdahl, MD, of Vance Thompson Vision in Sioux Falls, S.D., consistent precision is the laser's chief draw.

The first question that eye surgeons and facility administrators must ask themselves with respect to laser cataract surgery is: What are the practical applications and clinical advantages of this technology? In short, what's in it for you and your patients?

• A precise process. Done by hand, cataract surgery involves a number of manual steps, including capsulotomy, the making of an incision in the capsular bag to gain access to a cataract-clouded lens. Such delicate maneuvers are invariably variable in their size, shape and orientation, which may influence outcomes from one case to another. To a large extent, laser-assisted surgery removes those variables, providing controlled, consistent and nearly perfect cuts every time.

• A streamlined process. "It wasn't too long ago that ultrasound phaco was the big new thing," remarks Robert P. Rivera, MD, director of clinical research at Hoopes Vision in Draper, Utah. Now that the femtosecond laser's ultra-short pulses can be used to quickly and effectively soften and fragment the nucleus of a cataract, many physicians are finding their need for phacoemulsification energy during a case reduced or even eliminated. "It allows you to get away from phacoemulsification altogether," says Dr. Rivera, who describes a slate of cases in which he used "zero phaco" for 8 consecutive cataracts. "Without any is just remarkable, a huge step forward."

Q-EYE "It's a fundamental core belief of our practice, that if there's something we can do a little bit better for our patients, we're going to do it," says Dr. Berdahl.

• The best possible outcomes. Ideally, the ability to replicate the technique will let physicians fine-tune other factors and replicate results. "A precision capsulotomy, the same every time, takes that variability out," says John Berdahl, MD, an ophthalmic surgeon with Vance Thompson Vision in Sioux Falls, S.D. "Then the noise decreases, and you can focus on the next imperfection," such as the variabilities involved in selecting the type and power of the intraoperative lens.

• Innovative patient care. "It's a fundamental core belief of our practice, that if there's something we can do a little bit better for our patients, we're going to do it," says Dr. Berdahl. He notes that the advance appeal of the technology to patients and their perioperative and post-discharge satisfaction with the results cannot be discounted.

"The biggest part is understanding the value proposition to the patient. People are seeking us out for this technology," he says. Approximately 30% to 40% of the practice's cataract patients go under the laser. "But even if they don't choose to go with laser, we've found they feel good that they had that as an available option. And patient satisfaction means robust business."

"Patients are demanding more freedom from glasses," says Dr. Rivera, whose practice's specialization in laser refractive procedures led it to pursue laser cataracts. "The medical outcome [of eye surgery] is to free patients from cataracts. The refractive outcome is to free them from glasses. These 2 goals are merging. Femto-phaco is taking us to that stage."

What are your options?
At present, 4 femtosecond laser platforms have received the U.S. Food and Drug Administration's 510(k) clearance for use in cataract surgery and for purchase in the U.S.:

• Alcon Laboratories' LenSx Laser (www.lensxlasers.com)
• Bausch & Lomb's Victus Femtosecond Laser Platform (tinyurl.com/b6dqsov)
• the LensAR Laser System (www.lensar.com)
• Optimedica's Catalys Precision Laser System (www.optimedica.com)

WHAT IS A FEMTOSECOND?
A 1 Followed By 15 Zeros

CUT ONCE T. Hunter Newsom, MD, of the Tampa (Fla.) Surgery Center prepares for a femtosecond incision.

Cataract surgeries are known to be short, efficient undertakings, but manual incisions, limbal relaxing incisions and capsulorhexis have nothing on femtosecond lasers, the precise and ultra-short pulses that could revolutionize the procedure. But what is a femtosecond? It's one-millionth of a nanosecond (itself a billionth of a second). In other words, one-quadrillionth of a second. (A quadr-illion is a 1 followed by 15 zeros). How fast is your surgeon's scalpel hand?

— David Bernard

According to industry observers, the systems differ in several technical aspects, including their lasers' "behavior" (beam profiles, pulse width, duration and repetition rate, for instance); their imaging capabilities for scanning and measuring ocular anatomy; and how the laser apparatus comes in contact, or "docks," with the corneal surface of a patient's eye — a detail that reportedly can affect the shape of the eye during treatment, and subsequently the incisions made.

There's no convenient way to demonstrate and trial this technology on human patients in conference exhibit halls or even in your own surgical suites. And it's difficult to ascertain whether the technology will provide you with improved outcomes unless you actually test-drive it. So how should you choose?

As the earliest of early adopters (in 2011, they were the fifth practice in the world to purchase a laser system), Dr. Berdahl's center's options were limited: only the LenSx platform had at that point earned FDA clearance. Plus, a senior partner in the practice had played a role in the clinical testing during its development. "It was the only choice," he says, "but we'd still choose it."

Even if you're not an early adopter and didn't have a hand in building the technology, his reason why may still resonate: manufacturer reputation. "We're a brand-agnostic practice," he says. "We use all kinds of lenses and instrumentation. We make our decisions based on the best technology. But it's hard to overestimate a big eye care company putting a ton of resources behind this. They're not going away, and access to service and support from the company's engineers and trainers anytime is much appreciated."

Dr. Rivera's practice also invested in the first-on-the-market LenSx machine in 2011. Once other manufacturers' options became available the following year, though, it purchased Optimedica's Catalys system due to the physicians' preference for its results. "Obviously, if we're going to spend more money for technology to do the same thing," he says, "we want it to do the same thing better." It's a rare center that owns 2 different laser systems, but the physicians predominantly use the Catalys.

In his experience, word gets around when it comes to new technology. So if you're considering adding a laser to your cataract surgery services, do your homework. "Speak to as many surgeons and practices as you can. Make visits to see the technology in action. Nothing can take the place of that level of dedication of doing research. If you speak only to company representatives, they have a vested interest in their technology, and you'll likely just leave with their message."

Can you afford a laser?
There's no getting around it: A femtosecond laser represents a significant capital expense, one that will range from $350,000 to half a million, plus technical staff, service agreements, maintenance and other ongoing costs of ownership.

Without question, cost considerations are a major factor in a laser purchasing decision, and case volume is the answer. Keep in mind that laser use is elective, requiring patients to cover what insurance doesn't, and that even if the laser procedure is offered to every cataract patient, not all of them will choose to undergo it.

High-volume, eye-only practices seem to be the most likely candidates to make the scheduling quota. At Dr. Rivera's Hoopes Vision, 50 to 60 patients a month (about 60% to 70% of incoming patients) are choosing lasers. "With more public awareness, we expect that number to rise," he says. At Vance Thompson Vision, Dr. Berdahl says, "We thought we had to do about 400 cases a year to break even." After performing 1,000 cases in the first year, however, they realized that less than 400 cases would have sufficed for a solvent service line.

One ophthalmic services company's website calculates that a $425,000 laser (with associated costs) that costs a facility $17,100 per month and generates a profit of about $800 per case will require 21 cases a month before reaching the break-even point. If such a purchase price is too steep for your current budget, perhaps contracting with a specialized equipment-outsourcing firm would be more viable (see "Equipment Outsourcing Service Offering Laser Systems").

Will it fit into your facility?
A cataract laser doesn't require specialized infrastructure to operate, but it's not exactly plug-and-play either. Surgeons and staff must undergo training to use the technology, and Dr. Berdahl de-scribes performing 10 cases under the supervision of a proctor.

As far as installation and implementation is concerned, the more make-or-break issue is whether your facility has the necessary physical space available to house the equipment. "Can you accommodate the footprint in your space?" asks Dr. Rivera. "I'm aware of many situations in which the answer is no." You'll need at least an 8-foot-by-10-foot room, he says, because a laser system is about the size of a small compact car.

Manufacturers note that their systems are not intended for installation in ORs, with all the other surgical technology, but rather in procedure rooms of their own. Dr. Rivera's practice had a spare OR that the laser occupied, and the physicians have since moved into a new facility with a designated laser area, but he's heard of facilities that have torn down walls and renovated spaces for laser surgery.

Dr. Berdahl's practice has likewise built a surgery center specifically around laser cataract procedures, with 2 ORs and a laser in a pre-op bay. The LenSx's particular configuration also helps. "The LenSx doesn't have a fixed bed, which is a big advantage," he says. "The attached bed not only makes a bigger footprint, but you also can't just bring the patient in on a stretcher to operate. You have to bring them in on a chair, transfer them to the bed, then back to the chair."

Besides the physical bulk of its equipment, laser cataract surgery may demand some rethinking and adaptation of your surgical schedule. While femtosecond lasers can reduce or eliminate the need for blades and ultrasonic handpieces, some manual phacoemulsification may still be necessary, and manual irrigation and aspiration is required. Many practitioners are performing the laser and manual stages in 2 different rooms, and some have assigned the 2 stages to different physicians.

"The perfect staffing model to make laser surgery as efficient as possible has not been established yet," says Dr. Rivera, who notes that laser use can consequently add to case times. "Not by much, 4 to 5 minutes extra, but it adds up if you're used to a run of 20 cases." As a result, if you schedule mornings or afternoons full of cataracts, it would be advisable to note how many are femto cases and adjust accordingly, he says.

What's next?
Consider the advances that have brought major changes to cataract surgery in recent decades: phacoemulsification, intraoperative lenses, small gauge instrumentation, the femtosecond laser. It's reasonable to imagine they'll be even more integrated in the future, says Dr. Berdahl, especially as market competition boosts capabilities, lowers price points and, most importantly, supports better clinical outcomes.

"You should do what you believe in your heart is best for your patients," says Dr. Berdahl. "If you feel like the technology is better, you should adapt it."

If you're not convinced that the technology is better, though, wait and see. It's always improving. "The first generation colored a lot of impressions," says Dr. Rivera. "People who'd only experienced that might walk away thinking femtosecond lasers aren't ready. If a surgeon does not feel that it's here to stay, they need to take another look. Maybe they haven't seen the latest technology."

In fact, a software upgrade to the LenSx at Hoopes Vision has smoothed out some of the kinks that Dr. Rivera and his colleagues found less than ideal, he notes, improving its operation to the point that they're planning a controlled study of LenSx versus Catalys outcomes in the near future.

Laser technology in cataract surgery, he says, "makes a good surgeon great, and a great surgeon superior."