Controversy on benefits, drawbacks of LRCS continues

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Use of a femtosecond laser for cataract surgery is accompanied by increases in cost and time. However, available information on these and other issues support the procedure.

By Cheryl Guttman Krader; Reviewed by Deepinder K. Dhaliwal, MD, LAc, and John Hovanesian, MD

Debate continues about the pros and cons of laser refractive cataract surgery (LRCS) with critics often raising concerns about its association with increased cost and time. These and other issues were reviewed by Deepinder K. Dhaliwal, MD, L.Ac, and John Hovanesian, MD, in a point-counterpoint discussion.

Longer procedure, more costly

Dr. Dhaliwal, associate professor of ophthalmology, University of Pittsburgh School of Medicine, and director of Cornea and Refractive Surgery, UPMC Eye Center, Pittsburgh, presented data to defend the argument that LRCS takes too long and is too expensive. She reviewed videos from procedures performed by colleagues that demonstrated the LRCS procedure took 10 minutes longer than the manual case.

In addition, Dr. Dhaliwal reviewed a study undertaken by surgeons at Bascom Palmer Eye Institute (BPEI) that generated results consistent with the two case examples. The BPEI study included data from 311 routine cataract surgeries performed by three surgeons during the first 6 months after the cataract femtosecond laser was installed in the operating room. All three surgeons had experience using a femtosecond laser for refractive surgery and so were familiar with the docking procedure and case planning.

For each surgeon, average operating room time was significantly shorter for the manual procedures than for the LRCS cases, with the mean difference ranging from 11.1 to 13.4 minutes.

“Side-by-side viewing of the two videos from the cases performed show that while the manual case is already well under way, the surgeon is still performing the docking step with the femtosecond laser,” Dr. Dhaliwal said. “The total case time is what is critically important, and not measures like effective phaco time. Surgeons who perform just six LRCS cases a day would be adding at least 1 hour to the time spent in the operating room.”

Data to support the argument that LRCS is too expensive is even more clear-cut, Dr. Dhaliwal said, noting that the added costs include an average of $425,000 for a laser, $40,000 per year for maintenance, and $350 per case for the patient interface.

Time and cost acceptable

Dr. Hovanesian defended the position that the procedure time and cost of LRCS are acceptable based on the premise that the procedure delivers superior outcomes.

“What matters is not how long we spend in the operating room, but how good are our patients’ results,” said Dr. Hovanesian, private practice, Laguna Hills, CA, and clinical faculty, Jules Stein Eye Institute, University of Californiam Los Angeles.

Noting that LRCS has evolved significantly since its initial introduction, Dr. Hovanesian cited recent data to address various prevailing myths.

Concerning the idea that LRCS takes more time and does not reduce the use of BSS or phaco energy, Dr. Hovanesian discussed a recent paper from German surgeons showing the LRCS procedure required less balanced salt solution than traditional surgery while surgical time was similar for the two procedures. Multiple studies show a reduction in phaco energy use with LRCS, Dr. Hovanesian said.

“LRCS involves time moving patients between instruments, but we are paid for that time by patients who are willing to pay extra for the safety and visual benefits of LRCS,” Dr. Hovanesian said.

Data from other recent studies evaluating changes in objective measures of procedural safety-including anterior chamber flare, central corneal thickness, and endothelial cell counts-refute the idea that the laser causes more inflammation and is more damaging to the eye.

Findings in a survey involving about half of the laser cataract surgeons across the United States rebut the idea that patients are not willing to pay for LRCS. According to the survey, which represented nearly 38,000 procedures, practices found no change in the number of premium IOL implantations performed after adopting the laser. The survey also showed that patients receiving conventional IOLs comprised about half of the LRCS cases.

“In other words, use of this technology is not just isolated to patients choosing toric or presbyopic IOLs. Rather, it is attractive to everyone who wants better safety,” Dr. Hovanesian said.

He noted that adoption of the femtosecond laser is also important because it allows for other advantages and new opportunities. For example, the laser-created capsulotomy is stronger and more resistant to radicalizing than a hand-made capsulotomy. In addition, the laser can be used to create a posterior capsulotomy, which makes it valuable in pediatric cataract surgery and with the anticipated introduction of the bag-in-the-lens IOL.

Dr. Hovanesian concluded, “Whether you look at cost, technical issues, time, or expense, LRCS has risen to meet the demands and presents a safer and technologically advanced approach.”

Deepinder K. Dhaliwal, MD

E: dhaliwaldk@upmc.edu

Dr. Dhaliwal has no relevant financial interests to disclose.

John Hovanesian, MD

E: jhovanesian@harvardeye.com

Dr. Hovanesian is a consultant to Abbott Medical Optics and Bausch + Lomb. Dr. Dhaliwal and Dr. Hovanesian presented these views in a point-counterpoint discussion during Refractive Surgery Subspecialty Day at the 2013 meeting of the American Academy of Ophthalmology.