More Views on the Economics of Femtosecond Cataract Surgery

By Linda Roach

If money were no object, many ophthalmologists throughout Latin America would be investing in one of the four femtosecond cataract lasers now marketed internationally.

But even Ramon Naranjo-Tackman, MD, whose surgeries in Mexico City helped bring a femtosecond cataract laser to market, has been without one since the device company reclaimed the laser he had been testing.

“A lot of surgeons are interested in femtosecond laser cataract surgery, but they have no money to buy a laser,” he said. “It is too expensive, at least for the present economy in Latin America. And I think it’s the same for the whole world.”

In Italy and the United Kingdom, things aren’t quite that tough, according to two surgeons who each acquired a femtosecond laser within the last year. However, the economic outcome of those decisions for their practices remains unsettled, they said.

Their downbeat assessment contrasts with the experiences reported by surgeons from Germany and Australia in the July issue of Refractive Surgery Outlook.

This month, we interviewed:

Dr. Naranjo-Tackman, who is an assistant professor of ophthalmology at La Universidad Nacional Autonoma de México in México City. Until earlier this year, he was a clinical investigator for LensAR (Winter Park, Fla.).
Luciano Buratto, MD, medical director of Centro Ambrosiano di Microchirurgia Oculare in Milan, Italy. His facility installed a LenSx femtosecond laser (Alcon, Ft. Worth, Texas) last September.
Sheraz Daya, MD, medical director of the Centre for Sight, East Grinstead, U.K. In April, his eye center acquired a VICTUS femtosecond laser (Bausch+Lomb, Rochester, N.Y. / Technolas Perfect Vision, Munich, Germany).

In Mexico, Italy and the U.K., a femtosecond laser for cataract surgery is a very unlikely acquisition for financially-pressed government facilities, the three surgeons said. Government-paid health care programs pay only for conventional cataract surgery and implantation of a monofocal IOL; no balance billing is allowed. So anyone who wants a premium IOL or femtosecond laser surgery must go to a private facility and pay the full cost.

Surgery Fees Flat

While Dr. Buratto and Dr. Daya are among the first in their countries to offer the new procedure, this has not increased their profit margins because they have not yet raised their fees.

“I’m not charging my patients more for femtosecond procedures, but I have 50 percent more patients now coming to me for surgery,” Dr. Buratto said. “This is reimbursing me for the additional costs, but after that, I am not making any more money than before the laser.”

He has performed approximately 400 laser cataract surgeries with his LenSx laser since September 2011. He and Dr. Daya said they do not want to charge more until they feel confident that, in their hands, the femtosecond laser is giving patients better postoperative outcomes than with conventional surgery.

“Today the laser is giving something more to our patients, but not enough to increase our fees for the surgery,” Dr. Buratto said. “I am wanting to give them much more than we used to give with phaco.”

“I need to take a look at the data and make sure that the complication rates are better,” Dr. Daya said. “Then I can turn around to patients and give them a convincing reason that a femtosecond procedure is better than phaco. I need to give them more than saying, ‘It’s a perfect circle.’”

Dr. Daya operates a fully private-pay surgery center where 95 percent of patients choose a premium IOL. Since April, he has performed approximately 80 femtosecond surgeries with a VICTUS femtosecond laser, all at no extra cost to patients.

“Having gone through the IntraLase experience, I’m being cautious about this,” he said.

He explained: After his clinic bought an IntraLase femtosecond laser (Abbott Medical Optics, Santa Ana, Calif.), he added £400 per eye to the price tag if patients wanted their LASIK flaps made with the laser instead of a mechanical microkeratome. They reacted angrily to the two-tier pricing system.

“Eventually a patient asked me, ‘Why are you even offering blade LASIK when you don't think it’s the best procedure?’ I thought about it and decided he was right,” Dr. Daya said.

“I put all my keratomes in storage and I just did IntraLASIK on everybody. We abandoned the two-tier pricing system and just raised our global LASIK fee by £400,” he said. “And I can see that eventually happening at my practice with femtosecond laser cataract surgery.”

Weak Demand

Currently, however, demand appears to be weak. Since the laser arrived in April, not a single patient has come to the Centre for Sight specifically to seek out laser cataract surgery, he said. His 80 laser cases were patients who chose that option after he told them about it.

“So my big worry is that, if I start charging extra, I won’t have any cataract surgery patients at all. I’d rather have them come through the door, even if all I do is get my costs back,” Dr. Daya said.

Price concerns are theoretical for Dr. Naranjo-Tackman in Mexico. He worked with the LensAR laser during the design and clinical trial phases, but then the company received marketing approval in the U.S. and Europe.

“We did the original studies with the alpha and beta models of LensAR. We did several hundreds of cases, and then the machine was removed. I haven’t used the machine for a couple of months,” he said.

He said there are three femtosecond lasers in commercial use in Mexico (all the Alcon LenSx), with a fourth one being installed later this summer. In the rest of Latin America he knows of a handful more, including two in Argentina and one in Chile.

He joked that he misses having a femtosecond laser for cataract surgery, “because I know that I have to concentrate again.”

More seriously, he explained: “In conventional phaco, you cannot be distracted for even a second. I know that I have to concentrate to make a centration that is as perfect as possible. With the laser, you are not distracted because you are making decisions all the time about what to do next. You have a factor in your favor – the chance to make it repeatable.”

Early Experiences: VICTUS

Introduced at last fall’s European Society of Cataract & Refractive Surgeons (ESCRS) meeting, the VICTUS femtosecond laser received the European CE mark in December.

“The experience actually has been very good,” Dr. Daya said of the procedures he has performed with it. “But it’s quite different from doing regular manual cataract surgery.”

He said his impressions so far are that it creates a good circular capsulorrhexis, which is stronger postoperatively than in manual cases; has fewer complications; and provides greater stability at three months postop. The small spot size and fast repetition rates of the VICTUS cut efficiently, yielding a high proportion of free-floating capsules, and reduce the amount of phaco energy needed later. He adds that the small spot size also minimizes plasma bubbles.

Going Without Hydrodissection

“When you create all the plasma inside the lens, you are in fact helping the dissection of the nucleus and the cortex. So you don’t need to use that much hydrodissection. You can use it, but it is not a forceful step of the surgery,” Dr. Naranjo-Tackman said.

“Instead, you can go in, inject a small amount of water, and then try to remove the nucleus. Or you can go directly and aspirate it with a little phaco power.”

Dr. Daya agreed that changes in technique are necessary. “With conventional surgeries, I used to like doing cortical cleavage. But with the laser, I found that hydrodissection cannot work for me in the same way, and I now have a different way of dealing with the nucleus and the capsule.”

He developed a new technique he plans to present at the ESCRS meeting in the fall. “I have a technique of hydrodissecting that really frees up the lens and helps it break up.”

Room for Improvements

Dr. Buratto, one of the pioneers of posterior chamber IOLs in Europe, is philosophical about the bumps he has encountered over the past year while working with the LenSx. “Any new procedure at the beginning will not give all the results you expect it to give,” he said.

“My experience with the laser is getting better and better and better. Every software upgrade, it’s getting better,” he added. “But not as much as we expected when we started this new venture.”

For instance: “The repeatability is not happening at this moment,” he said.

Astigmatic keratotomies are imprecise, he said. “The incisions look good, but we don’t have a nice, perfect nomogram to be able to plan the postoperative astigmatism correction,” he said.

The system includes OCT capability, but there is no nomogram to factor the information optimally into the treatment plan.

The suction applanation causes high IOP lasting about three minutes, even if the surgeon is well-experienced, Dr. Buratto said. “In my opinion, having the suction ring on for that long is not good for the patient, so we have to reduce that time,” he said.

Advice from a Femto-veteran

Because Dr. Naranjo-Tackman is known for his extensive femtosecond surgery experience, colleagues frequently ask him whether they should buy a cataract laser now. Interest is particularly high in Argentina, Brazil and Chile, he said.

“They ask me for my personal opinion, and I always answer with an example,” he said. His parable goes like this:

“Let’s say you drive a Mercedes Benz. It has a very high price, and it is sophisticated. It will take you safe and comfortably, with excellent music and air conditioning, to wherever you want to go.

“If you are one of those surgeons who really like to have other people’s attention, and you have the money, then you might buy a Bentley.

“Both cars will take you places, safely and comfortably and with excellent music, but who’s going to get more attention? The ophthalmologist driving the Bentley, or the one driving the Mercedes?”