Making the Case for Femto

It’s the future of cataract surgery, but some high-volume surgeons say the future is now.

This article appears in the April, 2013 edition of Ophthalmology Management


The use of femtosecond lasers in cataract surgery — for creating capsulorhexis and limbal relaxing incisions, among other tasks — has been a hit topic at ophthalmology meetings in recent years, but incorporating it into practice remains a formidable proposition for most. Tech-loving ophthalmologists have grown used to steep price tags for their laser devices, but the costs attached to FS systems may make even the biggest tech-geek surgeons think twice.

Larry Patterson, MD, of Crossville, Tenn., lays the situation out thus: “You’re paying close to $500,000 for the machine. And the treatment cards or patient interface — however it’s described — is an additional $320 to $350 per patient. Maintenance is about $40,000 a year. So you are going to need a fairly significant number to make that investment pay.” Dr. Patterson is chief medical editor of Ophthalmology Management.

With costs like that in an economy like this, how can a practice make FS financially viable? The debate over that question has been robust, and despite the seemingly significant costs, some surgeons have answered in the affirmative, even as others proceed cautiously.

You’ll Need Volume

Those costs Dr. Patterson cites limit FS to high-volume surgery centers for the time being, according to Farrell Tyson, MD, FACS, of Cape Coral Eye Center in Florida. “It is the future of cataract surgery,” he says, “but unless you have certain circumstances, the volumes necessary to make it financially viable are hard to come by.” Dr. Tyson authors the monthly “Management Essentials” column in Ophthalmology Management.

Dr. Patterson concurs. For surgeons in large groups or surgery centers, “it’s very easy to see where [femto] could make sense,” he says. Centers doing, say, 5,000 cataract cases a year, he notes, would need a conversion rate of only 10% to make the investment worthwhile. Smaller groups, much less solo practitioners, would not find it such an easy decision. “If you are doing 300 or 400 cases a year, it’s out of the question” he says. “If you are doing 1,000 cases a year, it may be viable. It just depends. That’s kind of borderline.” Dr. Patterson just started using an FS laser for cataract surgery on the Sightpath mobile laser platform.

A good, hard look at your practice’s demographics can help you determine if the numbers work in your favor, Dr. Patterson says. Practices with a high percentage of Medicare patients should think carefully before making the leap to femto. Practices in affluent metropolitan areas, however, are in the fortunate position of having a patient base that wants the best and is willing to pay for it. Such practices have a good chance of making the necessary numbers.

Weighing the Evidence

Typically, concern about costs would take a backseat to improved surgical outcomes. However, with FS cataract surgery, critics note, the high-level evidence that supports FS for delivering improved surgical outcomes has yet to be published. “The question in doctors’ minds is, Is it going to improve it enough to make a difference? We are still waiting for a definitive study showing that,” Dr. Patterson explains. While he acknowledges that some small studies have demonstrated improved outcomes with FS surgery, Dr. Patterson points out that as of yet, no large, randomized studies have proven the value of FS.

Dr. Tyson, who does not have an FS laser, is similarly cautious. He concedes FS may make a difference for certain IOLs, such as the Crystalens (Bausch + Lomb, Aliso Viejo, Calif.) and the Synchrony (Visiogen, Abbott Medical Optics, Santa Ana, Calif.) (the latter is not yet FDA-approved). “I would probably question some of these smaller studies, in the amount of improvement in hitting your target,” he says. “Before we had lasers, we were able to sit there and do studies on capsulorhexis, symmetry and size and we were not able to prove an improvement in outcomes whether the capsulorhexis was overlapping or symmetric.”

Proponents of FS concede that the large studies proving the technology’s superiority to hand-cut capsulorhexis and arcuate incisions do not yet exist — but they emphasize the “yet.” Bob Lamont, CEO of The Eye Center of Central PA in Pennsylvania, is convinced they will come. When patient vision counselors at the practice explain FS to patients, they compare the incisions FS creates to the perfect circle a laser printer creates versus the circle the hand draws. Patients can grasp the potential benefits of FS.

The Efficiency Issue

If the verdict is still out that FS improves outcomes, then can it at least increase a surgeon’s efficiency? Dr. Tyson points out that using FS for cataract surgery actually increases case times. CMS recently reduced its reimbursement for cataract surgery, citing the reduced national average for surgery times — from 35 minutes down to 25. FS may only add five minutes to the procedure, but that does not include the time required to move the patient from the laser to the bed, as well as getting the patient prepped and draped, Dr. Tyson points out.

For surgeons whose procedure times are faster than the national average, that five-plus minutes represents an even bigger reduction in productivity. Dr. Tyson says he has heard of practices trying to offset this productivity drop by hiring an ophthalmologist to perform the FS portion of the surgery while another surgeon removes the cataracts in the OR. That may keep the surgeon’s productivity up, but it also means another cost for the practice — in addition to the costs for laser and maintenance fees. Can you convert still more patients in order to pay those extra costs?

Robert P. Rivera, MD, an intraocular lens and refractive surgeon and director of clinical research at Hoopes Vision in Sandy, Utah, believes that the enhanced patient experience the newer femto platforms deliver will bring in the additional volumes needed, thus overcoming any increased surgical times. “Some platforms really do have a better impact and a better benefit, both to the practice and to the patient,” he says. Dr. Rivera worked with FS since it was launched in the US market. The positive outcomes and the patient word-of-mouth he is confident will come will offset a slight reduction in surgical efficiency — and probably sooner rather than later. (Dr. Rivera’s practice uses both the Catylys (OptiMedica) and LensX (Alcon Surgical) FS platforms).

Are Patients Seeking FS?

And as word-of-mouth spreads, those taking to the Internet to find the local practices that offer the cutting-edge technologies — and isn’t that nearly all patients, these days? — may find your new FS a big draw. However, if the FS is already making inroads in your area, Dr. Tyson says there may not be much advantage in advertising a “me too” approach. Patients soon assume that everyone has it, he says, that it is simply the standard of care. 

When prospective cataract patients ask if he uses a laser, Dr. Tyson can tell them that he owns five different lasers. “I tell them that the laser I use in cataract surgery measures the eye intraoperatively and tells me what lens to use, what power, where to place the lens and what rotation.” Patients asking about FS have even boosted conversion to premium IOLs in his practice, Dr. Tyson reports.

Clinical Advantages of FS

A key advantage of the FS laser is that it makes a fully reproducible incision each time. Even the best surgeon does not perform optimally all the time, Mr. Lamont points out: A capsulorhexis held on too long, a diamond blade that gets away from the surgeon while making an arcuate incision, a patient who moves during surgery causing a jerk upward or downward. The FS laser, however, avoids these problems. Further, the laser can make a self-sealing wound. “So if we just put those pieces together, we can all agree that femto is better in this instance, can’t we?” Mr. Lamont asks.

Dr. Rivera lists additional clinical advantages of FS. Some studies comparing femto-phaco to standard cataract surgery show femto-phaco requires less phaco energy, he notes. “What femto-phaco does is, it softens the cataract,” he explains. “It turns the cataract from a harder substance to a much, much softer one. And that makes the surgery far less traumatic on the eye. In our experience, the eye heals quicker, the patient has a less cumbersome outcome, less decreased vision,”

He also explains to patients that FS allows him to address their astigmatism more aggressively than was previously possible.

Manual vs. Automatic

Dr. Patterson agrees with the proponents of FS on these issues — to a point. “Is it better? Sure. I’d rather you make a capsulorhexis in my eye with a laser as opposed to doing it by hand, but having said that, a very good surgeon can do an equally or nearly equally good job manually.”However, if the lasers aren’t quite there yet as far as the outcomes they can deliver, he thinks they will be. “I think it will be better with the laser; it makes sense, especially as the lasers get better,” he says. Some of the problems with the early models have been fixed, Dr. Patterson notes, and the platforms continue to improve.

Mr. Lamont believes the forward momentum of technology will win out. “When does technology ever go backward?” he asks. “People may have to pay a little bit more, but they don’t want to go backwards.”

Making the Numbers Work

As Dr. Patterson makes clear, volume matters with FS. Mr. Lamont says that practices considering the technology “need to sit down and do a simple formula.”

You must determine how many eyes you need to do with FS each month to break even. You need to account for the mortgage on the FS platform, the cost of supplies and other items to arrive at the fee to charge patients. Then, as Dr. Patterson advises, take a look at the patient demographics of your practice. Can you count on persuading that many people each month to convert to FS?

Relying on advertising for persuasion is not necessary, according to Mr. Lamont. Patient counselors — “vision education specialists,” as they are known at The Eye Center of Central PA, where they were already employed by the practice to help cataract patients understand their options — interact with patients one on one. “Our counselors were already teaching patients about IOLs and accommodating multifocals,” Mr. Lamont says. “We just asked them to talk about femto cataract surgery too.” Asking these counselors to include FS in the menu of options didn’t add another expense to the bottom line.

Surgeon Conviction Counts, too

Don’t just rely on employees to create enthusiasm for FS, however. Dr. Rivera maintains that surgeon conviction counts, too. “Patients tend to listen to their surgeons more than you may realize,” he says. He believes that acceptance of FS is often relatively easy because patients are familiar with lasers. They understand the idea of lasers providing results “much easier than they understand the concept of multifocal lenses or toric lenses,” Dr. Rivera says. “When I talk to them about multifocal lenses or torics, there’s a point at which their eyes kind of glaze over; they don’t get the concept as quickly. But everybody knows — everybody knows — that lasers are better. Lasers provide you a more modern, state-of-the-art type experience.”

And don’t let the absence of Medicare reimbursement scare you away from bringing FS into your practice, Mr. Lamont says. He has found that many doctors seem to operate under the belief that if they can’t offer something to patients for free, “it’s wrong. I don’t see it that way.” FS is an emerging technology, and whether Medicare ever reimburses for it, the better visual outcomes for the patient will be undeniable. “Shouldn’t patients then have the opportunity to get it if they see value in it?” he asks.