Why surgeons should not undersell their femtosecond laser

By Keith A. Walter, MD, Special to Ophthalmology Times

Keith A. Walter, MDWhen it comes to their eyes, patients want the safest treatments, and they know the best technology available is a laser. The cataract patient demographic is changing, and patients today have active lifestyles that demand functional vision.

They are traveling, use smartphones, and many continue to work. They have lived through decades of rapid technological innovation and understand that the best tools make great surgeons even better. 

Purchasing a femtosecond laser is a significant investment, and surgeons should maximize the benefits the laser offers to themselves and patients. Converting patients from phacoemulsification to femtosecond laser-assisted surgery (FLACS) is easy when physicians take the opportunity to educate patients on the benefits. Patients can feel assured knowing their surgeon is delivering the best care with the best equipment available.

At my office, we follow a simple education plan, which has produced a consistent 70% conversion rate for the past several years (despite a moderate-income patient demographic and a location in rural North Carolina).

It starts with education

The office mails every patient who makes an appointment an informational packet. This includes a welcome letter informing patients that they have two decisions to make: manual cataract surgery or femtosecond laser surgery and a standard or premium intraocular lens (IOL) implant.

Although the literature does not discuss pricing, the letter says most insurance plans cover standard options. However, the premium options require an out-of-pocket payment.

The office also include brochures about the non-covered insurance options, including the femtosecond laser and toric and multifocal lenses, so patients become familiar with the benefits associated with these alternatives. When patients arrive at the office for the initial consult, they already have been thinking about these decisions and are not blindsided by a sales pitch. They come prepared to have this discussion.

The majority of my patients already are sold on the laser before they arrive for the consultation. It makes sense to them that a precision laser is safer than a hand-held blade.

I take this opportunity to explain that although the femtosecond laser provides additional safety and produces better outcomes, the Centers for Medicare & Medicaid Services (CMS) categorize the femtosecond laser as a non-covered service because it corrects and manages astigmatism. CMS regulations do not permit billing for “better and safer,” we can only charge for the “non-essential” cylinder correction.

I tell patients considering the laser that I will remove existing astigmatism greater than 0.25 D and we will prevent any blade-induced astigmatism. Besides better vision and outcomes, opting for the laser procedure eliminates the human factor of variability and the potential complications associated with using a blade.

I express my enthusiasm about the laser, and my patients feel my genuine confidence in the laser. I always will recommend FLACS if they can afford it.

FLACS: Making good surgeons even better

FLACS makes good surgeons better

In addition to increased safety, FLACS enables surgeons to perform four moderately difficult steps easily and perfectly, unlocking other benefits such as shorter surgical time, a perfect capsulotomy and lens fragmentation, a better rotating lens, and a tight wound at the incision site.

First, the laser performs a perfect arcuate incision, eliminating the subjective method of going by “feel” when performed manually. There is no concern about the blade going in too soon or too far–avoiding complications such as iris prolapse caused by a short incision or a difficult view caused by a long incision.

Secondly, a perfectly round and exactly sized capsulotomy is completed in 1.6 seconds (30 to 60 seconds for a manual procedure). My practice uses the Catalys Precision Laser (Abbott Medical Optics), which scans the entire cornea and the lens within the pupil to create a 3D image of the eye.

Sophisticated algorithms then process the OCT image and accurately detect surface tissues–automatically creating a safety zone to maintain adequate distance from the posterior capsule and iris, as well as compensate for any lens tilt or decentration from docking.

Figure 1: Capsulotomy grid pattern (Courtesy of Keith A. Walter, MD)

The surgeon then verifies these images and selects from a number of automatic centering methods for the capsulotomy. Manual cutting may go radial and cause the lens to drop into the back of the eye or vitreous prolapse, resulting in an aborted procedure.

The third benefit occurs in the hydrodissection stage. The laser creates gas “pockets” within the capsular bag that help dissect the lens from the cortical layer without creating zonular stress and dehiscence around the capsular bag. In many cases, I have bypassed hydrodissection, and the cataract still is mobile.

Finally, FLACS fragments the lens in a grid pattern (Figure 1), producing a perfect crack down the middle. Reducing the amount of phaco or ultrasound energy required is safer on the corneal endothelium and iris.

Would you like a premium lens with that?

Would you like a premium lens with that?

Patients who accept the laser are also candidates for a premium lens. Just as the fast-food cashier asks, “Do you want fries with that?”

I ask patients if they would like a multifocal lens (and the possibility of eliminating glasses) to complement the laser procedure. Generally, if patients are committed to the laser and spending out of pocket, it is a natural step to take them to the next level.

Multifocal IOLs require extreme precision for a successful result, and the laser is the only way to guarantee that. I quote the cost for a multifocal IOL to include the laser procedure (This is CMS approved.), and I will not insert a premium lens in tandem with a manual procedure.

For patients who have a financial hardship, I do not upsell them to a multifocal IOL because FLACS and premium lens are not mutually exclusive. To confirm that this is what they want, I follow up by asking if they are comfortable with being in bifocal lenses following the procedure.

If this is unacceptable and they want a premium lens, I explain that this is only achievable with a multifocal lens and the laser. We do not insert multifocal lenses unless we are sure we can achieve the desired outcome.

Manual procedures are prone to a torn capsule, and we want to sharpen the astigmatism and perfectly place the lens. As long as patients know what to expect, they are not disappointed by the outcome.

Femtosecond lasers are an asset capable of delivering tremendous benefits to both the practice and the patients, and physicians should not undersell its capabilities. Patient education and surgeon enthusiasm go a long way towards influencing patients to accept (and pay for) a higher level of treatment.

Keith A. Walter, MD

E kwalter@wakehealth.edu

Dr. Walter is professor of surgical sciences at Wake Forest University Eye Center, Winston-Salem, NC. He specializes in cornea and refractive surgery. Dr. Walter is a consultant and speaker for Abbott.