Femtosecond laser assisted cataract surgery has become the hot topic at meetings both nationally and internationally. Physicians are proud to present the latest data as well as demonstrate how challenging cases were made simple with the new technology. There is no question in my mind that one day this will become standard of care, but is today that day? I say not at all.
First, there is the issue of cost. Most lasers today cost half a million dollars, and that does not include the associated royalty fees that come with each use. Combining all associated expenses, this amounts to approximately $400/eye. Physicians are not allowed to charge patients to upgrade to this technology; they must either purchase a presbyopic/toric lens or have laser performed LRIs. Some physicians have skirted this requirement, charging patients for LRIs for <0.5D of astigmatism. Ethics aside, the added costs of this technology raise patient significantly without any return to the provider.
Second, many have suggested that by performing a titrated perfectly centered capsulorhexis, that a more predictable ELP (effective lens position) can be obtained providing better accuracy. Working with residents and fellows who perform all types of capsulorhexi, I have never noticed any correlation with anterior capsulorhexis and accurace of IOL predictions. Furthermore, accuracy can only be as good as the lenses one is using, with most IOLs only manufactured in 0.5D steps.
While many physicians state less phaco time is needed in these cases, phaco time is still needed. Furthermore, the surgery can become technically more challenging: the laser capsulorhexis can weld the capsule to the underlying cortex, making hydrodissection more difficult. In addition, the laser cuts of cortical material make aspiration of cortex more difficult, potentially increasing the amount of residual lens epithelial cells and PCO rates. Cavitation bubbles must also be released from the lens before proceeding with phacoemulsification. While this step can be time consuming, not doing so may result in a posterior capsule blowout.
ASC workflow is also greatly disrupted. The femtosecond laser currently requires approximately 3 minutes of suction to perform all of its steps. It is not known if this prolonged pressurization of the eye may predispose some patients to intraoperative complications. In any case, this does not include getting the patient properly positioned in the room and into the OR. In the end this may result in an extra 10-15 minutes of patient time, 5 minutes of physician time, and most likely an additional employee to monitor the laser. Let’s also hope that the laser never fails. Unlike phaco machines where backups are aplenty, most users will only purchase one femtosecond laser, meaning any problems require cancellation of cases. To cancel surgery for premium lens patients on the day of surgery is not an ideal practice building model.
Of course there are also those patients who may be poor candidates altogether. Diabetics, uveitics, pseudoexfoliation, and Flomax users may all have poorly dilating pupils which current femto technology cannot address. How will the surgeon counsel the patient with poorly dilating pupils who desires a multifocal lens but wants “the best technology”? What will he/she say to combat his/her own marketing claiming a “safer, more precise way to do cataract surgery”? Additionally, how will they combat the negative criticisms from their competition telling patients that they are wasting their money on this technology?
Ultimately, femtosecond technology will advance to a point where we truly can provide safer and more predictable cataract surgery. That time is not now, but it may come soon on the horizon. As more devices become approved for sale in the US, pressures will increase to have the best laser, and this competition always drives innovation.