The use of femtosecond laser technology to perform key parts of cataract surgery (e.g., incisions, capsulotomy and softening the nucleus) continues to be controversial—not because of any problem with the technology, but because it’s expensive relative to the perceived amount of improvement it brings to the procedure. Compounding the problem, reimbursement from insurance companies and Medicare is very limited. As a result, many surgeons are hesitant to invest in the technology.

Questions that arise when surgeons consider adding this to their armamentarium include: Will there be enough reimbursable uses to make the purchase worthwhile? Will patients be willing to pay extra for the technology to be used? How much does the economic status of your patient base matter? And is it possible to earn back the cost of the equipment in a reasonable amount of time? Here, three surgeons who have used this technology for several years share their experiences.

When Is the Laser Being Used?

Karl Stonecipher, MD, medical director for TLC Laser Eye Centers in Greensboro, N.C., and clinical associate professor of ophthalmology at the University of North Carolina, explains that there are three situations in which most surgeons who have access to the technology use a femtosecond laser to perform cataract surgery: as part of a premium procedure; in response to surgical concerns; or for its diagnostic capability—specifically, optical coherence tomography. “We cannot get reimbursed for using the laser, per se,” he notes. “So if you’re using femtosecond laser for cataract, the patient is probably getting a premium lens of some kind—toric, multifocal or accommodating. Most surgeons don’t use femtosecond laser for a standard procedure.

“Of course, there are exceptions to that rule,” he continues. “I’ll perform femtosecond laser cataract surgery if I have someone on Flomax, or someone with a white cataract, narrow angles, pseudoexfoliation, previous trauma or a previous vitrectomy; anything I think will make the surgery harder. Sometimes just using the laser minimizes a problem even if you couldn’t see it coming.
Many surgeons are using femtosecond laser cataract surgery as part of a premium channel offering; to help manage challenging surgical situations; or when its optical coherence tomographer can help visualize surgical issues (a use that is reimbursable, pictured above). ( Images courtesy Y. Ralph Chu, MD.)
I recently put a lens in a patient and the lens dislocated inferiorly; I repositioned it and it dislocated again. On the third attempt I sutured it to the iris. It turned out the patient had a coloboma I couldn’t see at the slit lamp. If I hadn’t used the femtosecond laser, I would have had vitreous everywhere. It would have been a much more complex procedure.”

Although the technology may be helpful in a therapeutic capacity, Dr. Stonecipher notes that this raises some questions. “Which patients really need it?” he asks. “Should you use it for every case that’s complicated? I think the laser has been shown to put less stress on the eye. It allows me to do the lion’s share of the procedure before I even go into the eye. If I can make the incisions, do the capsulotomy and soften the lens before I enter the eye, that’s going to make it easier for me to take that lens out.”

The other way to get reimbursed for use of the laser is to charge for using its OCT as a diagnostic aid—to check the condition of the zonules, for example. Dr. Stonecipher says the diagnostic OCT has helped him avoid trouble in numerous cases. “Recently I discovered that a patient had zonular dehiscence from trauma,” he says. “The patient never told me about it, and all I saw at the slit lamp was a little phacodonesis. Because of the OCT, I was prepared to put in a capsular tension ring prior to entering the eye, and that prevented a very complex surgery.

“The bottom line,” he says, “is that we can charge for the diagnostics; we can use the femtosecond laser as part of a premium channel package; we can charge for astigmatic surgery that uses the laser; we can charge for the premium IOL that is implanted with the help of the laser; but we can’t charge for the laser itself.”

Which Patients Want the Laser?

Of course, in many cases using the laser means more cost to the patient. That raises a key question: Under what circumstances are patients willing to agree to the added cost?

Y. Ralph Chu, MD, founder and medical director of Chu Vision Institute in Bloomington, Minn., and adjunct associate professor of ophthalmology at the University of Minnesota, says that currently 50 to 60 percent of his cataract surgery patients receive femtosecond laser cataract surgery. He believes the primary reason patients are open to considering femtosecond laser cataract surgery is the desire for a refractive result rather than a medical result.

“To me, cataract surgery can be seen as falling into two categories,” he explains. “For some patients it’s simply a medical procedure in which we’re removing a lens and putting in an implant, followed by basic refractive care, which means glasses. On the other hand, if the patient wants the ability to function as best he can, whether at distance or at near, without glasses—or at least with less dependence on glasses—that becomes refractive cataract surgery. Patients in the latter category are open to being educated and choosing to receive new technologies like femtosecond surgery, use of the ORA device and other technologies.”

Of course, many surgeons are concerned that their patients will balk at paying extra money for the use of the laser, but most surgeons using the technology seem to agree that this is less of an issue than they expected. Inder Paul Singh, MD, president of the Eye Centers of Racine and Kenosha in Wisconsin, notes that the part of the country in which he practices is not affluent and was hit fairly hard in the recent economic downturn. Nevertheless, he finds that many patients are interested in being treated with advanced technology, even if the cost is higher. (He offers the use of the laser during cataract surgery as a premium service for patients who would like to have it, in addition to those who need arcuate incisions or might have it bundled into a premium intraocular lens package. He does not own the laser himself; he convinced a local hospital to invest in the technology, and he takes his patients there for the surgery.) “Right now we have a 60- to 65-percent adoption rate in our area,” he says. “I don’t sell it, I don’t promote it, I don’t advertise it. We just educate patients about it in our office.”

Is it possible to predict which patients are more likely to agree to pay extra for more advanced technology? Dr. Chu says no. “You cannot judge a book by its cover,” he notes. “We get a wide range of patients who choose to do this kind of procedure, and their financial status may have nothing to do with it. It’s more of an attitude thing.

“One day, for example, I had two patients come in; one was a school lunch lady, the other was the CEO of a company,” he says. “You might have thought the CEO would have chosen to have the best technologies used in his surgery regardless of the cost, but his attitude was one of extreme frugality. That’s how he ran his company. So he chose not to do a premium IOL or any lasers. On the other hand, the school lunch lady said, ‘You know, I’ve never bought anything for myself, and this is the one thing I want to buy to improve myself.’ She wanted to be able to lift the covers on the food and not have her glasses fog up, so she could see the kids as she delivered the food to them. She got a great result with a premium lens and the lasers. So she’s happy—and he’s happy too. That experience acts as a reminder to me that I should never restrict which patients are introduced to these technologies, and that everyone deserves to know their options so they can make the best choices for themselves. After all, this is elective surgery.”

Dr. Singh also says he doesn’t assume anything about what a given patient may be willing or able to pay. “My job is not to sell premium procedures,” he says. “However, a lot of patients say, ‘Doc, what would you do?’ I say, ‘You know what? If it wasn’t for the money, I’d say why not do this? Why not have a precise capsulotomy and a precise arcuate incision and have less total ultrasound energy in the eye?’ I tell them if it wasn’t for the money, I wouldn’t be giving them a choice; I’d just use the more advanced technology. I really do believe it’s a better option for my patients.

“I tell patients that I’m not here to tell them what they can or cannot afford,” he continues. “Some patients ask me if they need to have the laser. They say, ‘I’ll mortgage my house to use the laser if you think it will make a big difference for me.’ I tell them that manual cataract surgery is still a very good, predictable surgery for the most part; they don’t have to have the laser. I’ll take good care of them either way. I try to be honest and let them know whether or not I think it will make a significant difference. If it’s a young person with an early cataract getting a standard lens with half a diopter of astigmatism, I can do manual LRIs and get a good result. I think you have to use your judgment, and you have to be honest when you help the patient make a decision.”

Dr. Singh admits that he does see a difference in the interest level of different age groups. “Patients who are younger than 65 tend to want to have the laser,” he says. “Patients who are 75 or 80-plus tend to say, ‘I’m not really worried about whether I have to wear glasses or if I have a couple extra weeks of recovery. It’s OK, I can deal with that.’ Younger patients are more inclined to want the latest, best technology. They’re the iPad and iPhone users who think that if it’s newer, it’s got to be better. Some patients come into our office saying, ‘Doc, give me the best technology, I don’t care what it is.’ I say, ‘Wait—let’s talk about it.’ They say, ‘No that’s fine, just do it.’ ”


Clearly, even if a patient is interested and/or willing to pay for this technology to be used, he might not be a good candidate, either for medical or psychological reasons. “If the patient has the desire to have a refractive outcome,” says Dr. Chu, “then we ask a series of questions to determine whether she is a good candidate: Are her eyes healthy enough to achieve value from those extra technologies? Does she have macular degeneration or corneal pathology like basement membrane dystrophy, or a scar or glaucoma? I don’t think any one of those things is an absolute contraindication, but these are things the surgeon and patient have to consider when they’re thinking about femtosecond laser cataract surgery.”

“Medical contraindications would include corneal issues such as scarring that could interfere with docking; keratoconus; glaucoma surgery blebs; people who have corneal pannus, where you’re not going to be able to do a good corneal or arcuate incision; cases in which you don’t have good visualization of the extracapsular area; and patients with small pupils that might prevent a good capsulotomy or fragmentation pattern,” says Dr. Singh. “All of these medical conditions are a reason to say no. I’d also say no to a patient who is fidgety and apprehensive in general. You don’t want the patient shaking under the laser.

“From more of a psychological perspective, I think patients who have unrealistic expectations are a potential problem,” he says. “If the patient expects to have a perfect outcome because of the laser, that’s a contraindication. If they say they’ll pay more money if I can guarantee something, I wouldn’t want to go that way. I don’t want to use the laser and have them not get the outcome they’re expecting and then demand to know why.”

Dr. Chu agrees that unrealistic expectations could disqualify a patient, but believes that’s not limited to this situation. “I think that’s probably true across the board for eye care,” he says. “This is elective surgery. I think it’s important to assess whether someone has unrealistic expectations before surgery whether he’s getting the femtosecond laser or not. Some of our most difficult patients are those who haven’t chosen the femtosecond laser at all. They expect a refractive outcome because that’s what their friends got, even though they don’t opt for refractive cataract surgery using the best technology.”

Patients Who Ask for the Laser

Dr. Chu notes that an increasing number of patients are coming in asking specifically for femtosecond laser cataract surgery. “We’re seeing more and more of that,” he says. “As patients are forced to be more responsible for where their health-care dollar goes, they’re starting to look around more. And word does get out that these technologies exist. Patients are interested in seeing better, and they like the concept of laser surgery in general. I think the technology is showing that it can deliver, so if a patient comes in requesting it, that makes the discussion about the options pretty easy.

“On the other hand, you have to be careful,” he continues. “Many patients can’t afford the technology, and even if they find the idea appealing, they may not be looking for a refractive result. Right now, we can’t get reimbursed for using the laser unless we’re correcting astigmatism or utilizing the intraoperative imaging for a premium IOL; meanwhile, there’s a cost to the practice each time the laser is used. Ultimately, it’s up to the surgeon to use the tools needed to get the best outcome, whether the laser is reimbursed or not.”

Dr. Singh says that recently people have started coming into his practice specifically asking for the laser. “I’ve had access to the laser for a year and a half,” he notes. “It wasn’t until about a year after I started performing femtosecond laser cataract that I started seeing patients come in saying they’d heard about the laser and wanted it. Clearly, when a critical mass of patients has had it done, that has a marketing effect.

“It’s important to tell patients when you believe the use of the laser made a real difference in the outcome,” he continues. “I had a patient who had 2.5 D of cylinder; he wanted a special lens and it didn’t come in his power. So I had to make arcuate incisions to eliminate a lot of the astigmatism. He ended up 20/20. I said to him, ‘You would not be 20/20 if it wasn’t for those arcuate incisions I made with the laser, so the laser really did help you see better.’ He told his brother, who came in and wanted the laser as well. If the laser really does make a difference and you point that out and explain why, a happy patient will become your advocate out in the community.

“If a patient expects to have a perfect outcome because of the laser, that’s a contraindication.”
—Inder Paul Singh, MD 
“Of course, there have been some patients where I made a small arcuate incision with the laser that may or may not have made a difference in their quality of vision afterwards, but they’re happy that they got the laser and tend to assume the laser deserves the credit,” he continues. “I’m careful with those patients, because part of my job is to be fair and balanced. So I don’t tell them it’s because of the laser that they got their outcome. On the other hand, if a patient had a pseudoexfoliation issue or a tough capsule or a dense cataract, I will tell him that if he’d had a standard surgery, more than likely I would have had to use more energy inside the eye and he might have had less-sharp vision the next day. So in certain circumstances I will tell the patient that the laser made a difference. For the average patient I just say that I’m glad it went well.”

Dr. Stonecipher says he has also seen patients come in asking for the laser. “Of course, even patients who want the laser may have a problem affording it,” he notes. “You have to provide financing options for those patients. That’s another one of the options you have to offer in order to have success with the femtosecond laser.”

What about simply performing femtosecond laser cataract surgery on every cataract patient? “A few people have tried using the laser on every cataract patient,” Dr. Stonecipher says. “Shachar Tauber, MD, is still doing that and says his practice is making it work with volume by attracting many patients and community surgeons. But trying to do femtosecond laser on everybody without charging for a premium channel means you’re losing $350 a case. If you’re only making $350 a case, how’s that going to work out? You can’t compensate for that with volume. My partner tried using that business model, but it didn’t work. Without charging a premium to offset the laser fee it was just economically unworkable.”

Presenting the Option

Surgeons have differing opinions regarding whether the option of having femtosecond laser cataract surgery should be presented to every patient. Of course, the extra cost weighs heavily in that debate. “A lot of people desire refractive outcomes, but insurance covers less and less nowadays,” notes Dr. Chu. “So we have to talk about the cost. Patients have to pay more and more even for basic care, let alone some of the newer technologies, whether it’s lasers, implants or new pharmaceuticals. So cost becomes part of the discussion and part of the decision tree for patients. Unfortunately, cost is going to be an increasingly important factor in decision-making in every aspect of health care.

 “We’re not offering this option because we want to make more money,” he continues. “We want our patients to have as many options as possible, and when we talk to them we want to make sure they know about every option. I feel that if a patient isn’t educated and told about all of the available IOL options and all available technologies, including the excimer laser that can be used after cataract surgery to enhance the cataract surgery outcome, that’s a shame. So we’re passionate about education and letting patients make the best choices for themselves. We say to the patient, here’s the technology that’s available. There’s refractive cataract surgery and non-refractive cataract surgery. Here’s the technology that helps us achieve the result, and here’s the cost. It’s pretty straightforward, and there’s no pressure on the patient to choose one option over another. Patients have no problem telling us they don’t want to buy something.

“I’d feel bad if a patient who is interested in refractive cataract surgery or astigmatism correction said no one had told him about these technologies,” he adds. “I think that happens in a lot of practices. Sometimes patients come to us after having had surgery elsewhere and say, ‘Gosh, I wish I’d known about this.’ They may end up feeling like you hid something from them. So I’m really passionate about patients knowing that we offer all of these options, even if the patient isn’t a good candidate. If that’s the case, we still explain all the options, we just also explain that the patient isn’t a good candidate for this one or that one, and why.”

Dr. Stonecipher says that he used to tell every patient about the laser option, but no longer does. “I believe all our patients know that it’s an option,” he says. “It comes up somewhere in the discussions the patient has with staff members. But if I’m looking at you and you’re glazed over and you say you love your glasses and can’t afford anything, there’s no reason to go through that discussion. Talking about the option when the patient doesn’t want it or can’t afford it is just going to make the patient feel bad or believe you’re doing an inferior procedure.

“I tell my patients that I’m going to treat them as if they were members of my own family and do what I think is best for them,” he says. “If the patient is a candidate for a premium channel, I ask two questions: Do you want to be free of glasses? And if so, are you willing to pay for it? A lot of people say, ‘No, I’m fine, my wife wouldn’t recognize me without glasses!’ But if they say yes, then I have to explain why they need that better technology and, if necessary, offer suggestions as to how they can afford it.

“The other side of the coin is patients in whom I want to use the laser to make the surgery safer or easier,” he continues. “I do tell those patients about it. I may say, ‘You’ve got pseudoexfoliation syndrome and that’s going to make my job a little more of a challenge; I need you to let me use the diagnostics of this laser that costs $500 to help me do what I believe is a better surgery.’ Some patients will refuse, so I document our conversation in the chart.”

Dr. Singh sees several things as essential if you’re offering femtosecond laser cataract surgery to your patients. “First of all, any time we ask patients to pay more for something, it’s important to give them enough education about the benefits of that option to ensure that they understand its value,” he says. “It’s also important to make sure that everyone in the office is on the same page, because patients get information from everyone. That means you need to ensure that everyone provides similar answers when asked common questions like: What is cataract? What is astigmatism? What is a capsulotomy? What are the benefits of using the laser? Why is it important to have a perfectly centered, round capsulotomy? Why is it important to use less energy inside the eye? Why is it important to have astigmatism arcs that are perfectly cut to the exact depth? What do these factors mean for postoperative vision?

A few surgeons in the United States have tried performing femtosecond laser cataract surgery on every patient, but the limited reimbursement options have made it a challenge to remain profitable, even with increased volume. 
“Obviously we don’t want to inundate patients with too much knowledge because that could get confusing, but I want to make sure they understand why this laser, in my opinion as a physician, is worth the extra cost,” Dr. Singh says. “For me, education is the key. You can advertise all you want, but if patients don’t understand it they won’t be interested in it.

“The second thing that’s really important for making patients feel comfortable about having this procedure done is to be excited about the technology yourself,” he continues. “I don’t mean that you have to go out there and cheerlead for it; but I think it’s crucial that you believe in it. Doctors always say, ‘I don’t want to have to sell technology. I came here to be a doctor and do what’s best for the patient.’ I agree completely. If you don’t feel that the technology offers any benefit, then you shouldn’t be suggesting it. But if you feel that it does have some advantages, that’s a different story.

“I certainly would not say that it’s the right thing for every patient, or that every patient who has the femtosecond laser cataract procedure will have a better outcome,” he adds. “That’s not true. But I do tell patients that it helps me perform the procedure in a very predictable, precise way that may increase the likelihood of getting the best outcome. In my experience, that is true. So I believe if a patient can afford the more advanced technology, using it is worthwhile. You shouldn’t apologize for the increased cost; just explain the benefits you believe the patient will gain so the patient can make his or her own decision.”

But Is It Worth It?

Of course, many surgeons remain unconvinced that using the femtosecond laser as part of cataract surgery is worth the expense to the practice and the patient. Nevertheless, many who have used the laser disagree. “There are still a lot of surgeons out there that don’t believe the femtosecond laser adds much to cataract surgery,” says Dr. Stonecipher. “From my perspective, the femtosecond laser allows me to have a safer procedure when a case is potentially more complex. I think we’re seeing more and more published articles saying the laser helps you with one thing or another. It makes you a better surgeon in some areas.

“Can I implant a multifocal IOL without the laser? Yes I can, but we’re finding that effective lens position is really important in these patients,” he continues. “If angle alpha—not angle kappa—is off enough, these patients are never going to see well. Using the laser makes a big difference in getting the effective lens position right. There are still LASIK surgeons using bladed keratomes to make flaps. That’s fine, but it doesn’t mean that using a laser to make the flap adds nothing to the procedure.

“Last week I had two pseudoexfoliation patients; one agreed to the laser, the other said no,” he says. “Thankfully, nothing bad happened to the patient who elected to do a standard procedure, but it was a much harder procedure for me because she didn’t have good zonular support in certain areas. The patient who used the laser had a clear cornea and 20/30 vision at the three-hour visit; the other surgery took longer and the patient had corneal edema and 20/80 vision at the three-hour visit. Using the laser does make a difference.”

“I think we’re starting to see more data supporting the idea that femtosecond cataract surgery does have advantages over traditional phacoemulsification using ultrasound,” agrees Dr. Chu. “I agree that traditional cataract surgery is excellent; but once you start using the femtosecond laser, you do see some advantages, and those are beginning to come out in the studies. Patients get quicker visual recovery because there’s less ultrasound energy, and there’s less inflammation in the eye. We’re seeing better refractive outcomes and reduced enhancement rates with our premium IOL patients. So I do believe that over time we’ll see the femtosecond laser become an increasingly important part of cataract surgery.”

Dr. Stonecipher says he believes the femtosecond cataract laser technology is a worthwhile investment. “Most people are paying off the cost of the technology much more quickly than they expected,” he says. “We paid our laser off in three years, and we probably could have paid it off faster than that. Also, many people believe that it matters what part of the country you practice in and who your patient base is. I don’t agree. I think what does matter is what you feel is the best technology in your hands.”

“The hurdle that’s keeping everyone from using femtosecond surgery is the economics and the regulatory environment,” Dr. Chu concludes. “Right now it has to be used in a refractive cataract situation; it’s an expensive, premium technology. I think some things need to change before it becomes widely adopted as a good surgical tool that’s used for all patients. We’ll have to wait and see how it plays out, both in the marketplace and in the regulatory agencies.”  REVIEW

Dr. Chu is a consultant to Bausch + Lomb. Dr. Stonecipher is a consultant for Alcon, Bausch + Lomb and LenSx, and is a speaker for LENSAR and Abbott Medical Optics. Dr. Singh is a consultant and speaker for Bausch + Lomb.