The success of the femtosecond laser is no secret. Since its commercial debut in 2002, the IntraLase FS Laser System (Advanced Medical Optics, Inc., Santa Ana, California) has greatly influenced the business of refractive surgery. The current model, the 60 kHz IntraLase, creates a more precise stromal bed and adjustable flap, reduces procedure times, and improves outcomes—even compared with the laser's own previous generations. It has a tighter standard deviation compared with the microkeratome, with unique safety features such as cutting Bowman's membrane last compared with a mechanical microkeratome.
According to a Marketscope analysis, by the end of 2006, the IntraLase laser held a 30% share of the procedural market (LASIK) in the United States.1 As of November 2006, 1 million IntraLase LASIK procedures were performed.2 With this much success, what are the disadvantages of buying a femtosecond laser? For some surgeons, it is the price tag that goes along with owning such a device.
The IntraLase laser costs approximately $375,000 in the United States, and there is a $160 patient interface, or per-use, fee. Customers agree to a 5-year term, and the laser is serviced for $40,000 per year after the first year. Although the price is not cheap, the average practice will break even if they perform just 32 LASIK procedures per month. (The aforementioned statistics are derived from communication with Shareef Mahdavi, August 30, 2007.) The question that must be answered before purchasing a femtosecond laser is, then, can owning such a device be financially justified?
Most ophthalmologists are aware of the positive results that the femtosecond laser has achieved. Yet, the mechanical microkeratome is still an excellent and proven device. In fact, there have never been any studies confirming that one technology is safer than the other, although the femtosecond laser is more precise and creates a thinner planar flap. For the approximate 70% of ophthalmologists who have not yet purchased a femtosecond laser, most are thinking about it.
Before deciding that the purchase of a femtosecond laser is warranted, a surgeon must look at the big picture: How important is LASIK to the practice? If it is at the core of the practice, then the femtosecond laser is a serious consideration. Most surgeons who are committed to refractive surgery—including myself—fall into this category. If mostly cataract procedures are performed, however, and the use of a femtosecond laser would be mostly to offer touch-ups for cataract patients, the device is a much lower priority.
If the surgeon concludes that the femtosecond laser is a wise investment, they must offset the additional cost accrued by the practice, usually through increasing the cost of the procedure. On average, the typical practice will increase the cost of LASIK by $394 once a femtosecond laser is purchased.3 When offering a customized treatment, this number may differ. In my practice, we upcharge $400 for the IntraLase.
Alternately, some surgeons increase the cost of LASIK across the board. I do not think that one approach is better than the other. We are actually thinking about transitioning to a flat rate as well, because I have noticed that virtually every patient we service chooses IntraLase. According to a 2005 survey, surgeons with the IntraLase used the device in 88 of every 100 cases.3 Patients look at this technology just as they looked at the difference between radial keratotomy and excimer laser surgery. It is a difference between a blade and a laser—it is not difficult for patients to convert.
The average surgeon with higher conversion rates (ie, 60–100 cases per month) will experience a 10% increase in patient volume.3 This not only justifies the purchase of a femtosecond laser, but it also demonstrates an increase in revenue. If you are performing fewer than 30 LASIK procedures per month, however, then it becomes tough to justify the capital expense. So, my advice is if your practice has a high enough volume, consider buying a femtosecond laser. By adding this device to your practice and properly pricing the treatment, most practices can increase their profitability (Table 1).
I believe that the femtosecond laser is more than a trend. In the future, the vast majority of LASIK procedures—if not all—will be done with a femtosecond laser. I believe that in the United States, which is the market I am most familiar with, all-laser LASIK will become the standard. This transformation will not be overnight, just as it was not when the excimer laser took over radial keratotomy or when LASIK took over PRK, however, this transformation is inevitable. To me, the femtosecond laser is simply a more technologically advanced way to make a flap, and it is indeed financially justified if your patient volume is high enough.
Stephen G. Slade, MD, is in private practice in Houston. He states that he is a consultant to Advanced Medical Optics, Inc. Dr. Slade may be reached at +1 713 626 5544; sgs@visiontexas.com.
