Why the femto-cataract business model works


For the Aker Kasten Eye Center, the surgical benefits of switching to femtosecond laser cataract surgery have surpassed any initial financial concerns.


Take-home message: For the Aker Kasten Eye Center, the surgical benefits of switching to femtosecond laser cataract surgery have surpassed any initial financial concerns.



By Alan B. Aker, MD; Special to Ophthalmology Times

Boca Raton, FL-For several years, Aker Kasten Eye Center has been interested in the use of the femtosecond laser in conjunction with cataract surgery. Despite claims made by companies developing these laser platforms, the practice was skeptical and reluctant to acquire a system.

Early on, the companies were targeting the premium IOL market. Many studies touted improved IOL centration compared with manual.1-3

It was postulated that a perfectly round and centered capsulorhexis would improve outcomes because lens placement would be more precise. The practice doubted this claim because of experience observing capsule fibrosis and contraction during healing in the postoperative period.

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Though comfortable with the ability to produce a near-perfect rhexis, the practice had seen that a perfect circle can become an oval at the time of implantation. There was no reason to believe this would be different whether the rhexis was made by hand or using a femtosecond laser.

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In addition, the practice had seen late healing cause changes in lens position when capsule contraction occurred. Despite this, the practice continued to hear about this new paradigm for cataract surgery. The concept of ensuring a more secure final lens position and resultant better refractive outcome for patients seeking premium IOLs was the driving force in this marketing effort.

Next: Procedure improves with experience


The goal is to give patients the safest experience with the best possible results for cataract surgery. The way to do that is by protecting the corneal endothelium. Traditional phacoemulsification can damage intraocular structures,4 but through experience with the femtosecond laser thus far, the practice has seen a significant improvement in corneal health post-surgery.

It is believed the femtosecond laser represents a significant new technology to help further lessen phaco-related injury to the corneal endothelium.

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Though there is a learning curve when using the femtosecond laser platform, both surgical outcomes and overall safety considerably improve with experience.5

In addition, the amount of phacoemulsification energy used can drop significantly as comfort with this new technique is gained.

Burkhard Dick, MD, reported a significant reduction in phacoemulsification energy over time as he gained experience with femto-cataract surgery.6

Experience confirms this, and the practice now routinely performs phaco-free cataract surgery (Catalys Precision Laser System, Abbott Medical Optics).

After 8 months using this technology, the practice is pleased with this decision. Current conversion rate to the “premium channel” is averaging 70%.

In addition, the practice has seen an increase in patients selecting premium IOLs from 15% to 20%.

Next: Financial concerns


The main concern in converting to this approach for many surgeons has been the financial impact.

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The practice was also concerned about the potential impact an increase in fees for premium IOLs would have on patients. The practice was certain that adding cost for a femto procedure would put the price of premium IOLs beyond the reach of many patients. The business plan focusing on premium IOLs just did not make sense.

However, it was soon recognized that premium IOLs comprised only 15% of the practice’s annual surgical volume. It was at this point the practice began to focus on the remaining 85% of patients.

Any practice should make its own financial analysis to determine if the cost is justified. For the practice, it was believed the purchase of a femtosecond laser could be justified if the practice could capture 35% of those patients not opting for a premium IOL.

The goal has been far surpassed as a general average of 70% of patients now opt for femtosecond laser-assisted cataract surgery.

Other advantages

One of the most significant discoveries made is the advantage of using femtosecond laser with capsular tension rings (CTR) when using an accommodating, presbyopia-correcting IOL.

Next: Long term advantages


The fastest growth in the practice has been the use of the femtosecond laser, followed by a brisk demand for presbyopia correction (Crystalens, Bausch + Lomb). This demand is a direct result of the excellent results achieved when using a CTR in this situation.

In the move from traditional phaco to femtosecond laser-assisted cataract surgery, the practice now had an essentially perfect rhexis that was also perfectly centered. This capsule complex is still subject to changes-both at the time of implantation due to asymmetrical zonular integrity, as well as during the healing period.

By placing a CTR, the possibility of those changes is essentially neutralized.

This has translated into the best results the practice has seen with the premium lenses. The practice typically has crystal-clear corneas and close to 20/20 acuity in all patients 1-day postoperatively.

Thanks to the stabilization of the capsule and rhexis at the time of surgery, these results hold long term.



1. Nagy Z. Comparative analysis of the femtolaser-assisted and manual capsulorhexis during phacoemulsification [abstract]. In: Program and Abstracts of XXVIII Congress of the ESCRS Paris, France: 4–8 September 2010.

2. Batlle J. Prospective study of size and shape accuracy of Optimedica Femtosecond Laser Capsulotomy vs. manual capsulorhexis [abstract]. In: Program and Abstracts of XXVIII Congress of the ESCRS Paris, France: 4–8 September 2010.

3. Kranitz K, Takacs A, Mihaltz K, Kovacs I, Knorz MC, Nagy ZZ. Femtosecond laser capsulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011;27:558–563.

4. Walkow T, Anders N, Klebe S. Endothelial cell loss after phacoemulsification: relation to preoperative and intraoperative parameters. J Cataract Refract Surg. 2000;26:727-732.

5. Roberts TV, Lawless M, Bali SJ, Hodge C, Sutton G. Surgical outcomes and safety of femtosecond laser cataract surgery; a prospective study of 1500 consecutive cases. Ophthalmology. 2013;120:227–233.

6. Dick HB, Schultz T. On the way to zero phaco. J Cataract Refract Surg. 2013;39:1442-1444.



Alan B. Aker, MD

E: yodeler@akerkasten.com

Dr. Aker is co-founder and medical director, Aker Kasten Eye Center, Boca Raton, FL. He did not indicate any proprietary interest in the subject matter.


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