Picture this: You’ve just spent $400,000 on a femtosecond laser for cataract surgery, and then one morning you walk into the operating room to find it broken and shoved against the wall. Though it sounds like a fictional worst-case scenario, it actually happened to Denver ophthalmologist Michael Taravella. “We thought, OK, we have to find a separate room for this laser,” recalls Dr. Taravella, who had placed the laser in an OR he shared with surgeons and staff from other specialties who had made it a habit of bumping it out of their way. He says that this dark episode illustrates just one potential issue that can crop up when a surgeon invests in this new technology and then has to address the logistics of making it work in his surgery center. In this article, surgeons and surgery-center experts share their tips on how you can incorporate the femtosecond without slowing down.

Scheduling Cases

Surgeons say your cases will take longer when you first begin using the laser, but you’ll speed up with experience. However, they note that even then it will usually take more time than a non-laser case. Moran Eye Center surgeon Alan Crandall, whose practice was the second to purchase a femto-cataract laser in the United States, says everyone who works with the laser needs to get comfortable. “Initially, your techs aren’t super comfortable with it and so on,” he says. “So I’d say it adds eight to 10 minutes to your case until techs get comfortable with the steps involved.” You’ll eventually shave this time down, though.

“When the doctor gets familiar with docking and the staff gets comfortable with the laser programming, they can bring the added time down to maybe three or four minutes,” says Carlos Bravo, lead OR tech and materials manager for Specialty Surgical Center in Beverly Hills, Calif. Mr. Bravo makes sure the center’s flow isn’t impeded by the addition of femtosecond cataract cases. “When a surgeon begins using the femtosecond for cataract surgery, we block out about 10 to 15 extra minutes so there’s enough time for the learning process. Then, as he gets more efficient we take time off that. Now, some are even ahead of schedule because we’ve gotten that efficient. Part of this is because the intraoperative time is a little shorter due to the steps that were done with the femtosecond, such as fragmenting the cataract.”

Your practice will need at least one person to be trained in the programming of the laser in order to assist the surgeon. (Image courtesy Robert Rivera, MD.)
Mr. Bravo says scheduling multiple surgeons is another aspect that a center needs to address. “Here at the center, one of the biggest initial hurdles when femtosecond was introduced was the fact that we have several surgeons using it on any given day,” Mr. Bravo explains. “In the beginning, we used to spread them out and try to give a little time in between each femto case so we could turn over the room. But now we schedule them concurrently since all the doctors are familiar with the technology. A femto laser shouldn’t take longer than four or five minutes now. As soon as one patient is wheeled out, the next one comes right in. Initially, though, it takes time getting the staff trained. They also have to be efficient at getting the paperwork and other postop data that comes out of the femto case to the doctor so the next patient can come in.

“When multiple surgeons have femto cataracts on the same day, we have a first-come, first-served process,” Mr. Bravo adds. “There are times when we have three cases lined up one after the other. In those instances, we’ll come out to the preop area and say, ‘The laser room is open and whoever gets ready first gets to go in.’ In the beginning, though, these situations were an issue, since a doctor would point out that he was next on the schedule, but it would turn out his team wasn’t ready to move into the laser room. We had to get the doctors to communicate with each other. Let’s say that two doctors finish at the same time and each of their next cases is a femto. We’ll go up to them and say, “Both of you are finished, who would like to go first?” In many cases, one of them will say that he or she doesn’t mind waiting, and will let the other go ahead, since he knows that he can make up for any lost time in the OR.”

Sometimes, however, Mr. Bravo says femto cataract throws everyone a curveball, and the center has to be ready for it. “It just takes one patient who is uncooperative or maybe scared and uncomfortable with the laser process to disrupt the system,” he says. “If this happens we make sure that the nurse in the room lets the next surgeon know that we’re having issues so that he knows what’s going on and doesn’t get antsy. During our clinical training with the laser’s clinical application experts, they taught us how to recognize the danger signs, such as when a patient is moving his head a lot or is being uncooperative. At some point, you have to know when to stop. The surgeon will say, “We tried docking you and it didn’t work out, so we’ll do your case the traditional way—it’s not a problem.’ This is rare, though, and happens only 1 to 2 percent of the time at most.” Mr. Bravo says you can keep the patient flow going by recognizing potentially difficult patients before they’re under the laser. “Sometimes a doctor may come and tell us ahead of time that a patient may need a little extra sedation or a little extra time because he’s anxious,” he says. “Sometimes, a surgeon will schedule a potentially difficult patient, such as a patient with a small fissure, first or last in the lineup to keep him out of the way.”

Surgeons’ Experiences

Surgeons say it’s one thing to draw up a patient flow schedule on paper and another to put it into practice. Here’s what they’ve learned.

Sandy, Utah, surgeon Robert Rivera, who uses the AMO Catalys laser, has gone through a couple of ways of managing patient flow. “It does require the oversight of an ASC manager or charge nurse who can help you decide which system would work best,” he says. “For example, when I started, I thought I’d actually be more efficient doing two femtos at a time and always staying one femto ahead. That is to say I wouldn’t go into the actual operating room until I’d done two patients on the femto laser. Then, when I was done with the OR part of my first case, I’d go do another femto—this would be the third—and I’d then bring the second femto into the OR while the third was waiting. But, it turns out that, after the director of nursing helped us with a little time/efficiency study, we found out that in fact the easiest way for a single surgeon to do surgeries was to just do the femto on a patient and then bring that patient into the OR.” Dr. Rivera schedules all his femto cataract cases for the beginning of his surgery day.

Some surgeons, however, have had success with a patient-flow design in which non-femto cases are interspersed among the femto ones. “We tried a bunch of different ways at first,” recalls Dr. Crandall. “We tried to do them all at once but that wasn’t really efficient; the problem was you’d have to go back to the laser in between. It’s true that, once you got going, you could do this, but we found it was easier if you had a break in between because it was quicker for the team to have them all ready to go.

“For instance, in the way we do it now, I go into OR-1, and while I start a non-femto cataract there, my staff moves a femto patient into the LenSx room,” Dr. Crandall continues. “As soon as I’ve finished the non-femto cataract, I walk in to the LenSx room and they’ve got the laser ready to go and the patient situated. I do the LenSx, which now takes us about two to three minutes and, while that’s being done, the staff has already moved another non-femto patient into OR-2 for me. So I can go into OR-2, and they’ll take the LenSx patient I just completed into OR-1, and so on.”

Surgeons say that such approaches work for mild to moderate volumes of femto cataract patients, such as up to 40 percent or so. If the day ever came when a practice derived most of its volume from femto cataract, however, they say a two-surgeon approach might be best. “I believe the best system, if you have a sufficient volume of femto cataract cases, will be to have a dedicated surgeon doing the femtosecond part of the case,” says Dr. Rivera. “This will allow the anterior segment surgeon to stay in the OR.” Surgeons point out, however, that this ties up two surgeons, so the volume has to be there to support it.

Even without a high volume, having someone such as a subspecialty fellow around can help alleviate slowdowns. “In our center, the patients are assigned their surgical times before they even know whether they’re getting femto or not, and then we work it out,” explains Baylor College of Medicine Chair of Ophthalmology and Catalys user Doug Koch. “That may not be optimal, but it’s certainly convenient and saves a lot of headaches such as, ‘We should move Mary Smith over here because Peter Thomas is having that done, etc.’ It seems to make things simpler. On the day of surgery, as those femtosecond patients transition from one room to the next, I’ll step out and do the femto while my staff is either rolling the patient into the operating room or while my fellow is prepping and getting everything ready, and maybe making incisions and the capsulorhexis, in the other operating room. The time lost is quite minimal.”

Beverly Hills, Calif., surgeon Uday Devgan, whose practice has both an AMO Catalys and an Alcon LenSx, says that since the laser needs particular data before it can perform astigmatic incisions, it’s best to come prepared. “Write your exact LRI nomogram on the paperwork ahead of time so you can input it in the laser as soon as you get to the center,” he says. “It makes life much easier. Just get to the surgery center a half-hour early in the morning and program all your eyes for the day.”

Logistical Concerns

Experts say that, in order to make the big idea of femtosecond cataract surgery work, you have to consider several little ideas first.

 • The laser’s location. Though surgeons have the option of putting the laser in the OR or in a separate room, it seems like the consensus among experts is the latter is preferable.
To ensure an efficient docking process, make sure the patient’s cheek and brow are level, surgeons say. (Image courtesy Michael Taravella, MD.)
The main advantage of having it in the sterile OR is minimizing the transition time between the laser and the phaco machine. The disadvantages, however, are many. “If it’s in the OR, it’s paramount to make sure that whoever’s operating in that room is out by a certain time for the next surgeon,” says Richard Ferdon, a femtosecond applications expert for Alcon who trains practices on making the transition to femtosecond cataract. “So, for multiple physicians with multiple ORs and a high volume of cases, it’s best to position a laser outside the OR and put it in a procedure room. If there is a problem with a patient at the laser or a laser issue that needs repair, the entire operating room goes down and no one can use it. Having the laser in another room also becomes an extra location for patients to flow to.”

Dr. Taravella says putting his LenSx laser in the OR just caused it to be in the way of other surgeons and staff. “It was in a room that was used by non-eye surgeons,” he says. “The problem with that was it has a cooling fan or something that people didn’t like, so they’d try to move it or bump it. In fact, one morning we came in and found that a small arm connected to a light had been broken and was just dangling from the machine. Also, we had a lot of issues with having to re-calibrate it multiple times when it was in the OR because of someone bumping it. We found a home for it near the primary ORs. We’re currently remodeling the Eye Institute and it will eventually be in a room adjacent to the ORs and can feed the ones I’m working in.”

 • Prep the space. If you’re going to place the laser in its own room, the space it will require will depend on the model you purchase, but experts say to plan on a minimum of around 11 ft. x 12 ft, though some lasers may be able to squeeze into a smaller space. You may also have to do some renovations. “Prepping the space was a challenge,” says Mr. Bravo. “We had to install a cooling system and thermostat for the room to keep it between 65 and 78 degrees or so, and it had to be close to our wireless infrastructure so it could communicate with our printer and phone ports so it would have remote access.” Some lasers also need a 220 VAC power supply.

 • Mark the patients. Mr. Ferdon says everything in the femto cataract process should be managed in a written or symbol format. “The entire staff, from admitting to postop, has to be aware of which patients are which without interrupting or bothering the patients,” he says. “For instance, maybe change the color of the sticker on the operative eye to make the femtosecond patients’ a different color, and use different colored clips on their charts.” He says training the whole staff to be prepared for femtosecond patients avoids such situations as the anesthesia professional instilling a nerve block when the patient arrives that prevents the patient from moving the eye or fixating on the femtosecond’s fixation light. (Femto patients must be aware and able to participate for the femto portion of the procedure.)

 • Bed issues. An integrated patient bed may or may not be an issue for you, but it’s something to be aware of, surgeons say. “In terms of logistics, the LenSx is somewhat easier because with it the patient stays on the same gurney from preop to the LenSx laser, to the OR and then to recovery,” says Dr. Devgan. His Catalys has its own bed that the patient must be transferred to and from. The LensAR laser doesn’t have an integrated bed while the Bausch + Lomb Victus does.

The gurney used by the LenSx, though, may not work for all facilities, says Dr. Taravella. “LenSx touts its moveable bed as being able to be used in the OR,” he says. “But the problem for us is the laser isn’t sitting close enough to the ORs in our current situation so that we can use that bed. Our techs didn’t like it in terms of being able to roll patients any significant distance; it’s not really suitable for rolling more than 30 or 40 feet. Transferring patients back and forth between the conventional gurney and the LenSx laser gurney is probably the longest part of the procedure, actually.” He says in the pending renovation of his surgical center, the laser room will be close enough to the ORs that the patient can stay on the same gurney throughout.

Though adopting femtosecond cataract surgery technology may have its logistical logjams, surgeons say that you can make the process much easier if you can get your staff as motivated for it as you are. “The biggest advantage of the laser that the staff can readily see is how much easier it makes the removal of the cataract,” says Dr. Rivera. “When they see it takes less phaco energy and infusion fluid and so forth, and the surgery team reports back to the rest of the staff about the patient outcomes, that’s where the enthusiasm really comes in.”   REVIEW