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Innovations | Jun 2009

Implementing New Technologies at Refractive Clinics

Incorporate technology gradually and determine the financial feasibility before adding more.

Shinagawa LASIK Center was established in the Ginza section of Tokyo in October 2004. Although we started with only four refractive surgeons and their respective staff members, we now employ 140 doctors and 650 staff members, with branch clinics in Osaka, Nagoya, Fukuoka, and Yokohama. To date, the clinic has performed more than 500,000 total cases, with our LASIK volume expected to reach more than 290,000 this year (Figure 1). Each week, approximately 2,000 eyes are treated from Monday through Thursday and 2,400 from Friday through Sunday. This figure represents approximately 70% of all LASIK surgeries performed in Japan.

We have followed three simple principles at our clinic: provide the best treatment possible, provide the best service possible, and provide the best value possible for our patients. Although this strategy sounds simple, these principles are, in fact, difficult to achieve unless we offer patients the best procedures with the newest innovations and the latest technology. This article concentrates on our rationale for implementing new technologies into the clinical setting.

Almost all (95%) of the procedures we perform are LASIK surgeries; however, we also perform PRK, LASEK, phakic and multifocal IOL implantation, intrastromal corneal ring segments, and conductive keratoplasty. In June, we also plan to start using the AcuFocus Corneal Inlay ACI 7000 (AcuFocus, Inc., Irvine, California) as another treatment option for presbyopia. In these ways, we strive to stay ahead of the bell curve and be among the first refractive surgery centers in Japan to offer the newest techniques to our patients.

When the clinic opened in 2004, LASIK was typically performed using a mechanical microkeratome; IntraLase (Abbott Medical Optics Inc., Santa Ana, California) had not yet gained the popularity it now enjoys. However, after careful evaluation of clinical results, we became convinced that IntraLase was superior to the microkeratome in terms of flap thickness and positioning. Therefore, we implemented the exclusive use of the femtosecond laser for flap creation as soon as the clinic started treating patients. Our decision has proven to be a good one, as IntraLase is currently the dominant method of flap generation in Japan—it is used in 95% of LASIK surgeries.

The femtosecond laser makes it possible to achieve good results for all patients and minimizes differences between surgeons. We also use the femtosecond laser for implanting corneal ring segments and plan to use it for the AcuFocus Corneal Inlay in the near future.

There are other ways we have implemented new technology into our practice. First, we have recently started Z-LASIK, a procedure using the Femto LDV with the TopView camera (Ziemer Group AG, Port, Switzerland) for flap creation. We were interested in this new technology because it is designed to inhibit postoperative diffuse lamellar keratitis (DLK). We have purchased a few of the machines and are carefully tracking results. Thus far, we have noticed that the occurrence of DLK has been reduced; however, there are several items that must be improved. For example, each time the surgeon decides to change flap thickness, another kit must be opened. Also, when corneal ring segments are implanted or corneal implants performed, the surgeon must change the handpiece.

As a member of Ziemer's clinical advisory board and extended research and development team, I am able to provide advice and discuss a variety of issues with the people who develop the product. I feel that this close interaction with the development team will result in improved products and more effective techniques.

As another example, in May, the Shinagawa LASIK Center became the first clinic in Asia to introduce the new iFS laser (Abbott Medical Optics Inc.). When implementing new technologies, it is advisable to start with a small investment and evaluate the results, which is what we are doing with the iFS laser. From our results, we will determine the cost-effectiveness of this new technology and determine if it warrants further investment.

Implementing the latest technologies into practice benefits not only patients but also surgeons. Each investment we make must benefit both the patient and the clinic. The most important thing is that we should provide the best treatment available—otherwise, patients will stop visiting our clinic. As long as we keep providing patients with the best treatment possible, they will choose us over the next clinic.

Listening carefully to the opinions of doctors who are already using the latest technology or performing the newest techniques is also important. Additionally, seeing new technologies and deviced displayed by various companies at meetings and congresses, such as the European Society of Cataract and Refractive Surgeons (ESCRS), the American Society of Cataract and Refractive Surgery (ASCRS), or the American Academy of Ophthalmology (AAO), helps one to gather information on new technologies that may be worth purchasing.

Regarding the timing of implementing new equipment, it is advisable to start with the smallest volume. With new equipment, see if it is possible to sign up on a trial basis. Thus, you can benefit from new technologies at a low cost and with less risk. Once the new product has proven its effectiveness and you have evaluated its benefits, increase your purchases gradually. With any new product it is also important to evaluate the number of patients who will benefit from the new technology and determine the financial feasibility of implementing it.

Minoru Tomita, MD, PhD, is the Executive Director of the Shinagawa LASIK Center, Tokyo. Dr. Tomita states that he has no financial interest in the products or companies mentioned. He may be reached at e-mail: tomita@shinagawa.com.