Will 2014 be the ‘year of the laser’?

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Will 2014 be the ‘year of the laser’?

by Michelle Dalton EyeWorld Contributing Writer

Leading anterior segment surgeons seem to think so

Just a scant few years ago, the femtosecond laser was in its infancy with only a handful of surgeons investigating its uses beyond refractive surgery. Today, nary an anterior segment surgeon is unaware of the device’s potential in both corneal and cataract surgery. When it comes to the femtosecond laser for refractive cataract surgery, “we wanted to get involved right away,” said Mark Kontos, MD, in private practice, Empire Eye, Spokane, Wash., and Hayden, Idaho. The practice had a good relationship with Sightpath Medical (Bloomington, Minn.), and once the mobile ophthalmic service provider started offering a femto laser for cataract, Dr. Kontos immediately began using the service.

“It’s allowing us to use the LenSx [Alcon, Fort Worth, Texas] system and getting the experience many doctors are actively implementing these changes into their day-to-day develop the practice,” he said. “What I like about the Sightpath model is that we can take baby steps in integrating the system into our practice without having to purchase the system outright right away.”

For Vance Thompson, MD, director of refractive surgery, Vance Thompson Vision, Sioux Falls, S.D., the laser is just part of the group’s overall package offerings. “We market our refractive laser-assisted cataract surgery package as ‘ReLACS,’ and the laser is an integral part of it. Our laser-assisted cataract surgery includes incisions, capsulotomy, lens softening, and any astigmatic work in combination with intraoperative aberrometry for power documentation,” Dr. Thompson said. Patients have “a lot” of confidence in a laser’s capabilities, Dr. Thompson noted, and physicians know the laser can make incisions more precisely than the human hand. “Studies are now coming out to show that outcomes are better. The question others may still have is whether the improved outcomes are worth the price tag, and each practice needs to evaluate that for itself,” he said.

While the femtosecond laser may add a little more time to complete cases, the improved outcomes mean less postop chair time, said Robert P. Rivera, MD, director of clinical research, Hoopes Vision, Draper, Utah. “We recommend femto-phaco for patients who qualify as the best way to have cataract surgery performed today,” Dr. Rivera said. The average case adds about three to four minutes to the overall procedure, but those few minutes “add so much benefit to the patient’s visual outcomes that there’s no question in my mind it’s a worthwhile investment.” He also uses the device on complex cataract cases, such as zonular dehiscence. No matter how good a surgeon is, “occasionally a patient moves and all of a sudden, a perfectly normal case isn’t anymore,” Dr. Kontos said. Surgeons are beginning to embrace the laser’s ability to turn difficult cases into “more or less routine cases,” he said, and cited white cataracts as one example. “Problems you can’t get away from are now so much easier with the femto laser,” he said. “It takes all the anxiety about these complicated cases away. Is that enough of an many doctors are actively implementing these changes into their day-to-day routines.argument to convince people they should have one or have access to one? Maybe.”

Dr. Thompson was such a believer in the technology that his new surgical center was designed around the laser. “We’re not only working on a great patient experience, but from the moment cataract patients enter our atrium, it’s a very choreographed sequence of steps that has us treating them more like refractive patients.” His surgery center is somewhat circular in nature, so once patients sit in the chair, they are laid flat, moved to the femto, moved a few feet away for the rest of the intraocular work, and then returned to postop, all in the same chair. “It’s quite easy to do every step choreographed around laser cataract surgery,” he said. With several platforms available (and some approved for more indications than others), “surgeons have to do their homework to determine which choice is the best for their practice,” Dr. Rivera said.

What makes the case

Whenever technology is brought into a practice, “it has to make it easier for you, better for the patient, and profitable enough that you can justify it in your financials,” Dr. Rivera said. “From the patient perspective, they need to feel that if they’re paying extra it’s a worthwhile investment on their part.” If a surgeon isn’t convinced about the merits of the technology, the investment won’t be recouped, he said. “Once surgeons get the femto into their hands, they’re going to see consistently delivered results.”

For physicians who are debating the purchase, “bear in mind that for patients, it brings a lot of confidence. They already know cataract surgery is quite successful. They also know traditional cataract surgery is very dependent on their surgeon’s hands. But when we can add something like the laser to it that increases the precision of the procedure, that means a lot to the patient,” Dr. Thompson said. For patients with Fuchs’ corneal dystrophy, for instance, where the need to be as gentle as possible to the endothelium is of utmost importance, the laser reduces the amount of energy needed during the phaco portion, which reduces the stress on the eye—”so from a patient’s perspective, it’s a very attractive option.” He believes the more surgeons learn about the technology, the more they will embrace it and want it in their own centers. Dr. Kontos said 2014 is the year of the laser, at least for his facility. He plans on having a permanent laser by the end of 2014 (and the sooner, the better). Because his practice already has a high percentage of patients interested in premium lens technology, this is one additional piece of the puzzle that’s necessary. That said, he recommends people try out the platforms via Sightpath or in some other scenario to be “100% it’s the way you want to go in your practice.”
Dr. Thompson said 2014 won’t just be the year of the laser, it’ll be the year of premium vision. “For me, it’s all about the vision and what vision the patients want. Once they’ve made the decision about what type of vision they want (spectacles/no spectacles, readers only, accommodating or multifocal, etc.), then we talk about what are the best tools to help them maximize that vision,” he said.

The patient variable

Dr. Rivera has noted an upswing in the number of people in the community who are now insisting the femto be used on them during cataract surgery; they’ve gotten the information online and feel well informed, he said. “The outcomes are great and patients see so well postoperatively—even those with difficult cases going in—that the word of mouth is spreading rapidly,” he said. His center is still debating dedicating one surgeon to the laser and one to the OR for the remainder of the cataract procedure, but that may infringe upon surgeons’ clinic times.

The enthusiasm technology like the femto injects into a practice is “contagious,” Dr. Thompson said. “Patients know we’re doing cataract surgery with the world’s best technology.” As these lasers get into the hands of more surgeons, “it will many doctors are actively implementing these changes into their day-to-day routines.undoubtedly change the way we do cataract surgery,” Dr. Kontos said. “Laser is changing the face of phaco, and it will move us beyond just laser cataract surgery. We’ll start thinking about better ways to do cataract surgery that weren’t possible before.”