EYE ON INNOVATION Cataract surgeons are embracing several new technologies.

It's been less than 3 years since femtosecond lasers were approved for cataract surgery. While our recent reader survey on cataract technology shows that pockets of skepticism still exist, there also seems to be no question that acceptance and adoption have come more swiftly than most would have imagined. In fact, it appears likely that the holdouts will find themselves in the minority before long.

More than one-third (35.5%) of our respondents say they're already offering femto surgery at their facilities. And among those who aren't, one-third (33.1%) say they're either very or somewhat likely to join the movement in the next 2 years. Only about one-fifth (21.8%) say they're "not at all likely" to make femto an offering during that time period.

"The verdict is still out as far as whether the outcome is better for patients versus traditional phaco cataract removal," says Christy Lee, RN, BSN, CASC, NE-BC, administrator and clinical director of Surgery Center at the Forum in Columbia, Mo., but, she says, it's still "somewhat likely" that her center will take the plunge before long.

Clinical data is lacking, largely because the technology is so new, but the proponents of femto are increasingly convinced and increasingly enthusiastic. When we asked our panelists to name the most significant innovation or development in cataract surgery in the last 2 to 3 years, femto far outdistanced the rest of the field.

But there are still perceived obstacles, primarily the cost of the machine, the out-of-pocket costs for patients and surgeon acceptance. The fact is, not all steely nerved, highly experienced surgeons are willing to acknowledge that even the steadiest of hands may not be as precise as a laser.

"We have older surgeons," says Steven McCormack, DO, MHSA, an anesthesiologist at Mary Rutan Hospital in Bellefontaine, Ohio. "And I think there tends to be a bias against new technology. It may have to be driven either by new surgeons coming in, or by a public perception that it's something we need."

PAIN MANAGEMENT Ergonomic improvements for surgeons, including heads-up displays and adjustable oculars, are becoming the norm.

Is it needed?
When surgeons make incisions manually, "there's a lot of anxiety, whether they want to admit it or not," says Jerrie Graves, BHA, clinical liaison between the University of Houston College of Optometry (UHCO) Surgery Center and the University Eye Institute in Houston. "The laser has removed that anxiety. It's a wonderful piece of equipment."

The UHCO Surgery Center is now using the femto on an astounding 95% of its cases, says administrator Marilyn Christian, RN, BSN, CNOR, CASC. When the femto was approved by the FDA, "a few surgeons stood on the sidelines," she says, but the training and education provided by their vendor made the difference. "Now our doctors are all on board with the benefits, and of course they promote that to the patient."

Patients at UHCO pay an additional $500 out of pocket for the laser treatment, which is designed to cover the $340 the center pays for each cassette (the disposable patient interface), plus an added fee to help defray the purchase price of the machine and maintenance costs.

"When we explain to patients that we'll get to the same outcome but there's less swelling, less discomfort and less energy used in the eye, 9 times out of 10, patients will opt to have (the laser)," says Ms. Graves. "Surgeons meet with patients and say this is my preferred method (and) our patients are pretty much on board with what their surgeons recommend. They're generally willing to pay a little more out of pocket unless they're significantly indigent."

"Some of our commercial plans are beginning to pay for the laser," adds Ms. Christian.

But some facilities say both the upfront and the ongoing expenses related to femto are too daunting. "It's too costly and we can't get reimbursed," says Denise Carpenter, BSN, director of nursing at the Surgery Center of Northern California in Redding. "We would be unable to cover the cost of the laser based on the number of cases we do," says another facility leader.

Highlighting the need for strong vendor support, the clinical coordinator of a southern surgery center says her facility tried femto for a year but gave up: "Patients balked at the expense and there were technical issues with the laser itself. We were unable to maintain focus and alignment."

Outsourcing?
Most of our respondents either own or lease their femto lasers, but nearly one-fourth (24.3%) say they use outsourcing services that specialize in delivering and setting up equipment on a pre-specified number of days per month, and send skilled technicians to help facilitate and troubleshoot. The outsourcers charge a per-click fee, letting facilities with smaller patient bases cluster their cataract cases into the days they have the femto onsite.

Virtually all say they're either satisfied or very satisfied with their outsourcing arrangements. "They're friendly and they're willing to get us what we need when we need it," says Connie Galloway, RN, BSN, clinical coordinator of perioperative services at the Samaritan Regional Health System in Ashland, Ohio.

The case for LASIK
Our survey respondents are also intrigued by the prospect of broadening their offerings, with more than half (53.8%) saying the idea of having a femto laser that can also be used for LASIK — which at least 2 companies now offer — is either somewhat or very attractive.

"It would let us do more procedures on more patients by more doctors," says Pamela Borello, RN, BS, CNOR, clinical nurse manager of surgical services at St. John Macomb-Oakland Hospital, Oakland Center in Madison Heights, Mich.

Since LASIK isn't covered by Medicare or most private insurers, outpatient centers would be competing for patients who've already conveyed a willingness to pay out-of-pocket costs. The added safety of having the procedure done in an environment that requires a higher level of sterility could be a selling point.

GOAL ORIENTED Advanced lenses and innovative techniques are part of the quest for more precise outcomes.

"I think [accredited] ASCs are the safest place to do LASIK, versus a clinic or a doctor's office," says Hunter Newsom, MD, founder of the Newsom Eye & Laser Center in Tampa and Sebring, Fla. "I like being able to say I have an OR, I know it's following these safety guidelines, and there's an independent person verifying that."

Increasing the cash-pay patient population by adding LASIK is an intriguing idea, acknowledges a facility chief on the West Coast.

"It would increase our versatility and give us a higher potential for profits," adds the director of nursing at an East Coast surgery center.

Lens options
Nearly all respondents have embraced the improving technology surrounding intraocular lenses, with 90% saying they now offer toric IOLs and 85% offering multifocal IOLs. Quarter-diopter-step lenses are also finding their way, with 31% now making them available. Overall, advanced IOLs achieved runner-up status when it came to naming the most significant innovation of recent years.

In the quest to achieve more and more precise outcomes, arcuate corneal incisions (47%), digital marking through the microscope (25%) and intraoperative wavefront aberrometry (17%) are also finding increasing numbers of believers. Among our other survey findings:

• Surgeons are still a hard sell when it comes to guarded ophthalmic scalpels, with 64% of respondents saying they're never used at their facilities, and another 12% saying they're used in fewer than half of all cases. They just don't like the feel, say most of the resisters, with high cost and resistance to change also frequently cited as reasons.
• Preloaded IOL-injection systems have made their way into about one-fourth of our respondents' practices and get very high marks when it comes to efficiency, infection control and surgeon satisfaction, but slightly lower marks when it comes to cost.
• The vast majority of facilities are taking care of their surgeons' ergonomic needs, with 87% offering "heads-up" surgery — rather than being tethered to the optical eyepiece of the microscope, surgeons view high-definition displays of the surgical field of view in real-time on a 3D flat-panel display — 93% providing microscopes with adjustable oculars and 88% offering ergonomically engineered surgeon chairs.