FIRST STOP James Salz, MD, performs the laser portion of cataract surgery at his Los Angeles facility.

Standardized results. Less collateral damage. Better IOL placement. What's not to like about the latest innovation to cataract surgery? Femtosecond lasers are far from the current standard of care for one of surgery's most common procedures, but more physicians might consider using the technology when competition among manufacturers slashes start-up costs and savvy patients with expendable income seek out facilities equipped with eye surgery's next big thing.

A phaco-free future?
Femtosecond lasers use short pulses of energy to make precise cuts in the cornea that are unmatched by even the most skilled blade-wielding surgeons. The most important part of cataract surgery involves making the capsulorhexis, which the laser does perfectly almost every time.

Each laser system has its strong points. All are excellent, although surgeons might prefer the imaging capabilities of one to another. That's a crucial difference for surgeons, too. They need to gauge the thickness of cataracts, know how far below the cornea the laser will perform the capsulorhexis, and soften and pre-chop the lens nucleus. This requires working with a laser system that has excellent imaging capabilities.

Before laser procedures, patients are prepped as they are for conventional surgery. Instead of heading directly into the OR, however, they stop in a dedicated room for the laser portion of the procedure. Cycling patients through the laser treatment might add several minutes to overall procedure times, so high-volume surgeons might opt against using the laser.

We do at least 300 cataracts a month in 4 ORs, and have 2 systems located in a separate room, so using the laser doesn't slow patient flow. That's a crucial setup in order to maintain case efficiencies — surgeons whose primary focus is manual surgery, and who only perform the occasional laser case, aren't slowed by laser procedures performed in the OR.

PROFESSIONAL OPINION
When Do Lasers Work Best?

Using a femtosecond laser to perform cataract surgery is clinically justified if a patient has a significant amount of astigmatism to correct. What's a significant amount? Half a diopter? Three-quarters of a diopter? One diopter? That's often debated among ophthalmologists.

In my experience, patients with astigmatisms of .75 to 1.00 diopters are ideally suited for laser surgery, although astigmatisms up to 2.00 diopters can be adequately corrected with the systems. Beyond that, you have to use a toric lens to achieve positive post-op vision results.

By using the laser to correct astigmatisms, surgeons will also benefit from its ability to form perfect capsulorhexis and soften the cataract before removal.

— James Salz, MD

In the laser room, surgeons place a cone-like attachment on top of the patient's cornea to perform the capsulorhexis, the lens softening, the arcuate incisions for astigmatism and the incisions to enter the eye in the OR — all in a non-sterile field. Patients are then moved to the OR for lens removal with phacoemulsification and implantation of the new IOL.

Does laser cataract surgery result in better outcomes? That depends on whom you ask. Some surgeons swear by the blade and question switching from one of the safest and most predictable procedures in all of surgery to a technology that adds cost without delivering significantly better outcomes.

On the other hand, proponents of the laser say creating predictable cuts leads to improved IOL placement — making consistent capsulorhexes is more predictive of the proper position of the lens implant in the eye — for precise post-op vision outcomes with less astigmatism. That point is controversial, but there is some data that show it might be true.

In addition, the laser makes precise corneal incisions to solve pre-existing astigmatism. I've been really impressed with how much more accurately the laser lets surgeons correct astigmatism compared with what can be done by hand with diamond scalpels.

All of these potential benefits of laser cataract surgery don't take into account one of the most exciting aspects of bladeless surgery: Softening the cataract lens with the laser means less ultrasound energy is needed to remove it, which ultimately minimizes risks of damaging surrounding intraocular structures and the cornea, and results in less post-op inflammation and less time in the OR. Softening Grade I to Grade III cataracts with the laser ultimately makes removing them easier and offers the potential for doing so with just irrigation and aspiration. This phaco-free surgery is an exciting development that leads to safer procedures, clearer corneas and, ultimately, better post-op results.

BOTTOM LINE It has to make financial sense to dedicate space in your facility for laser procedures.

Costly upgrade
So what's preventing widespread use of the laser? More surgeons would use the technology if it were financially feasible. The technology is expensive — the units costs about $400,000, per-click charges run several hundred dollars and annual maintenance fees can add up.

Of course, facilities can negotiate different payment arrangements with manufacturers to cover the cost of the technology. They can lease the units or defer the start-up costs by securing the units free of charge and paying for the disposables used during each case — all of the laser systems require case packs containing syringes and the cone-shaped attachment. Partnering with an outsourcing company that sets up mobile units in your facility is another low-cost alternative for adding the technology.

Medicare won't reimburse directly for the use of the laser, but as with premium IOLs, facilities are allowed to upcharge patients for astigmatism-correcting surgery.

How much patients are willing to pay depends on your local market. In general, you can expect patients to pay a couple thousand dollars for vision upgrades. My facility in Beverly Hills might have more success finding a sufficient volume of willing patients than a small center in the Midwest, but for facilities that can tap into the right population, there's money to be made in lasers.

Can surgeons use the laser on patients who don't have astigmatisms? Sure, if they find a way to pay for it — notably by implanting a premium lens. They can certainly incorporate the cost of the laser in the extra $2,000 or so a patient might be willing to spend for a multi-focal or toric implant.