COMMAND CENTER Michael Blair, MD, of the Ford Eye Center in Fort Worth, Texas, says his femtosecond laser system offers him guidance during laser-assisted cataract procedures.

Laser cataract surgery is expensive, both for the patients who opt to pay out of pocket for the premium offering and for the surgeons who invest in a laser. The laser itself can cost $300,000 to $500,000, with additional costs for using ($300 to $350 per case) and maintaining the device. You'd think for that price, the laser would take the place of manual cataract surgery. But it doesn't.

Phacoemulsification is still used to remove the cataract itself. Instead, the laser assists in the removal of the cataract, performing some of the most challenging steps in cataract surgery traditionally done manually with the precision of advanced laser technology. The laser performs 3 key steps in the cataract surgery procedure that some say can cut surgical times by as much as half:

• the corneal incision
• the anterior capsulotomy
• lens and cataract fragmentation

Not having to move patients from bed to bed when you transport them from pre-op to the laser is a huge time-saver and safety element.

"I think the biggest advantage of laser cataract surgery is consistent capsulorhexis, which will lead to better lens position afterward," says ophthalmologist Michael Blair, MD, of the Ford Eye Center in Fort Worth, Texas.

The laser can also be used to make incisions in the cornea to treat certain types and amounts of astigmatism.

For patients who want the best possible vision, laser cataract surgery is appealing. A more accurate incision, capsulotomy and astigmatic correction may help patients achieve their goal of less dependence on glasses after cataract surgery. An increasing number of patients are asking their surgeons specifically for femtosecond laser cataract surgery. Dr. Blair is among the many surgeons who's using femtosecond laser cataracts as part of a premium channel offering. His tiered pricing:

• Distance plus. If the patient doesn't mind wearing readers after laser cataract surgery. $1,800 per eye.
• Astigmatism package. Femtosecond laser plus premium toric IOL. $2,200 per eye.
• Total vision package. Femtosecond laser plus multifocal IOL. $3,500 per eye.

Dr. Blair offers a free LASIK touchup if needed. Also included in his prices are all necessary testing and OCT (optical coherence tomography), a 3D imaging technology that helps cataract surgeons to plan the location and depth of incisions made during a laser-assisted cataract surgery procedure to make the cataract surgery as precise as possible.

How many laser cataract cases do you need to do to break even? For Dr. Blair, the magic number is 20 cases a month. "That's an important thing to look at," he says. "A facility needs to be sure it can convert enough cases to pay for the laser."

Do you have to move the patient?
One of the benefits of Dr. Blair's laser system is that it doesn't have a fixed bed. His patients are wheeled into the OR on an existing bed and positioned under the laser for that part of the surgery. Then, the bed is swiveled around, and the patient is prepped for phacoemulsification and lens implantation.

"Not having to move patients from bed to bed when you transport them from pre-op to the laser is a huge time-saver and safety element," he says. "It takes an additional 3 to 4 minutes to transfer each patient. It adds up. So it's efficient for us, and easier on our patients, too. Many have mobility issues. Some are larger."

Patricia Wyers, RN, BSN, CNOR, the OR team leader at the Northwest Michigan Surgery Center in Traverse City, Mich., says her center has had the laser for about a year, and so far the only complaint is from staffers about its integrated table. While some facilities keep the laser in the OR, she says theirs is in a separate room. That means that the patient is first taken to the laser for incisions and treatment of the cataracts and then moved into the OR for the manual part of the procedure.

"We have to get the patient off of the stretcher, move them onto the integrated bed, have them treated, and then wheel them out to our operating suite, where the surgery is finished," she says.

P. Dee G. Stephenson, MD, FACS, is president of the American College of Eye Surgeons and an ophthalmic surgeon at Stephenson Eye Associates in Venice, Fla. His machine lets a bed freely slide underneath it, reducing patient handling requirements for staff and lowering the machine's OR footprint. That's especially helpful in his smaller facility. He jokes he'd have to "knock down a wall" for some other systems. "It's small and compact and has great OCT. And it's got the iris registration with cyclotorsion," says Dr. Stephenson. "It's made femto for me not only slicker, but also safer."

The staff at Northwest Michigan Surgery Center appreciate laser system features that make surgery safer and tailored to the patient. One such feature is its docking system, or how its laser comes in contact with the corneal surface of the patient's eye. The system features a liquid optics interface that gently connects the laser and the eye, using a suction cup filled with a saline solution, says Ms. Wyers. This reduces the risk of high eye pressure that's sometimes seen in laser cataract surgery, distortion of the shape of the eye during treatment and patient discomfort.

Once docked, the system uses an OCT imaging technology to visualize the patient's eye. It then creates a map of anatomical landmarks, which helps the surgeon create a custom treatment plan. Once the surgeon confirms the plan, the femtosecond laser delivers precise pulses to his desired locations. "There are several different types of incision options available using the software, though not all of our surgeons use all of the options," she says. "They fine-tune treatment for each patient."

Dr. Stephenson says he was drawn to several key features in his laser cataract system that make surgery more efficient. He believes the system has "the best OCT for visualization" and also appreciates its easy-to-use liquid interface docking system.

The system's iris registration program also lets surgeons take a pre-op image of the topography of the eye in their office and wirelessly transmit it to the laser in the OR, notes Dr. Stephenson. This is extremely helpful for dealing with cyclotorsion, a natural movement of the eye that occurs when a patient moves from sitting up to lying down. "Let's say you decide in the office you're going to take the astigmatism at 90 degrees, or 12 o'clock. But when the patient lies down, that 12 o'clock becomes a 10 o'clock," he says. "This program adjusts the incision accordingly."

He also likes the system's cataract density-imaging program, which gives the user more choice in the fragmentation pattern used to break up the cataract. "It's much more efficient and delivers concentrated energy," he says. "And it can be customized for each individual patient."

How's the service?
Before purchasing a system, consider the service and training provided by the vendor. Ms. Wyers notes that after her center purchased the laser, the company sent reps in to train the surgeons and perform test runs in wet labs. Once initial training was complete, each surgeon was required to perform 10 cases with a rep's guidance.

"They're always available if we need help, too," says Ms. Wyers. "But from what I observed, the surgeons were comfortable after 10 times, especially the ones who were more computer savvy." So far, the system's intuitive user controls have ensured nearly problem-free implementation. "We've gone through a few troubleshooting phases, but it's pretty user-friendly overall," she adds.

When choosing his laser, Dr. Stephenson says he was attracted to the company's small size and excellent customer service. "It wasn't a big, huge corporation," he says. "The nice thing about it being a smaller company is that the engineers really listen to the surgeons, so we get things like upgrades or changes to the machine done much more quickly."

Laser cataract machines require a significant investment, but Ms. Wyers says her center was able to lessen its impact on their budget by partnering with the surgeons most interested in starting a laser program. Those ophthalmologists formed an LLC that eventually split the total cost of the capital purchase with the center. "It's very, very expensive," she says. "This way, not one group had to bear the full burden of the cost." OSM