Counterpoint: Waiting to Implement Laser Cataract Surgery

Why am I waiting to implement laser cataract surgery? The answer is simple: At this time and in this economy, I cannot make a reasonable business case to purchase a laser platform for a procedure that, in my hands, already has exceptionally good results.

Let me take a step back and describe my own practice setting first. I am a cataract surgery specialist in a large public hospital in the Netherlands, and the practice consists of nine ophthalmologists and one resident. The government controls health care and also fixes pricing, including that of cataract surgery. For the past 4 years, since 2008, copayment for premium IOLs has been allowed; however, out-of-pocket payments for medical care is a new concept for patients in this country.

PROS AND CONS OF LASER CATARACT SURGERY

I acknowledge the superiority of femtosecond laser capsulorrhexis creation compared with manual capsulorrhexis. Even in the best hands, a manual technique does not match the predictability of a laser. The femtosecond laser also has a theoretical advantage with regard to incisions of all types, but in my opinion this advantage is not as marked as the advantage of laser-assisted capsulorrhexis creation.

On the other hand, this potential superiority of laser cataract surgery involves a significant additional cost, which I would need to transfer to my patients. In order to profitably integrate laser cataract surgery into our practice, the extra cost to each patient would be between €800 and €1,000. Keeping this number in mind, I see no opportunity for a healthy business case proposal, nor a logical reason to convince my colleagues to purchase a laser at this time.

I anxiously await the review of clinical refractive outcomes with the laser versus traditional cataract surgery. I am comfortable with the concept of using the laser for multifocal IOL patients, but, because I am not a proponent of the light-splitting principle, I implant a relatively low number of multifocal IOLs. Therefore, for the vast majority of my patients who receive monofocal or toric monofocal IOLs, I do not anticipate a significant increase in patient outcomes and/or satisfaction with laser cataract surgery.

For these reasons, it would be difficult for me to counsel a monofocal IOL candidate to spend an exorbitant extra sum of money for an uncertain theoretical benefit. Conversely, I foresee a trend toward more aggressive marketing of laser cataract surgery, which could ultimately lead to lower pricing and general acceptance of this technology in the future.

Another aspect to address is the current limitation of the laser to cut the lens in manageable fragments. Denser nuclei and smaller pupils are still challenges to effective treatment with any femtosecond laser system. I am eager to see the progress of technology to improve the performance of laser cataract surgery in these challenging cases.

CONCLUSION

I am not positioning myself as a naysayer to laser cataract surgery, and I readily acknowledge that the procedure has the potential to create a paradigm shift in current treatment protocols. However, at this time, it financially does not make sense for me to adopt this technology. I plan to keep a close eye on the clinical refractive outcomes of other surgeons and will continue to weigh the benefits of this technology against its associated surgical upcharges.

Khiun F. Tjia, MD, is an Anterior Segment Specialist at the Isala Clinics, Zwolle, Netherlands. Dr. Tjia states that he is a consultant to Alcon Laboratories, Inc. He is the Chief Medical Editor of CRST Europe. Dr. Tjia may be reached at e-mail: kftjia@planet.nl.