Do Femtosecond Lasers Merit the Cost? Experts Disagree

Marcia Frellick

October 21, 2016

CHICAGO — The question of whether femtosecond-laser-assisted cataract surgery (FLACS) is worth the considerable cost or whether standard phacoemulsification is the way to go was the subject of a lively debate here at the American Academy of Ophthalmology 2016 Annual Meeting.

Dr Cionni: It's Better and Worth It

Speaking in support of FLACS was Robert Cionni, MD, medical director of the Eye Institute of Utah in Salt Lake City, who has performed more than 2600 of the million procedures performed worldwide.

About half the cataract surgeons in the United States offer FLACS now or plan to offer it in the next 12 months. And FLACS accounts for 8.8% of all cataract procedures in the United States, "which is up from 6.6% last year," Dr Cionni reported.

Some studies have shown that laser-assisted surgery is not superior to other techniques, he acknowledged, but those findings could have been affected by weaknesses in the trial design.

The biggest shortcoming is related to the estimation of the effective lens position. "It remains an estimate even with laser-assisted cataract surgery. The noise that is introduced into the [intraocular lens] calculation by the effective lens position is simply too great to demonstrate the superiority of one technique over another," he explained.

Among the many advantages of FLACS are the precision of capsulotomy, the lower cumulative dissipated energy, and the reduction in corneal endothelial cell loss. "Some studies have shown a lower vitreous loss rate, as well," said Dr Cionni.

 
Let's not repeat the past. Let's not knock the new technology because it's different. Dr Robert Cionni
 

Not all patients can or want to pay the higher price associated with the technology, "but those who do more than support the cost of our surgery center and the extra time spent by physicians," he reported.

He acknowledged that he is an experienced surgeon but said that FLACS takes him "no more than 2 minutes extra. Seven femto cases is the financial equivalent to us of 10 cataract procedures," he said, so the small investment of time is "certainly worth it."

Dr Cionni pointed out that there's no evidence that the refractory result is worse, and there is some evidence it is better.

"Let's not repeat the past. Let's not knock the new technology because it's different," he concluded.

Dr Braga-Mele: Not Worth the Expense

Arguing against FLACS was Rosa Braga-Mele, MD, professor of ophthalmology at the University of Toronto, Ontario, Canada.

She said she agrees that the cost of FLACS can be passed on to patients but pointed out that the steep learning curve and extra time required for the laser-assisted surgery will slow workflow, which is a deterrent.

The extra 2 minutes it takes for Dr Cionni to perform each procedure — after conducting 2600 surgeries — is great, "but for most of us, it will take 5 to 7 minutes for the first few cases," she said.

There are logistical considerations as well. "Where are you going to put the laser machine? It's hard to bring it into the OR because it's so large. You may have to build a separate room," she added.

Another consideration is potential postoperative complications. Research has shown that dry eye worsens after femtosecond cataract surgery. "Is that something we want in our premium [intraocular lens] patients?" Dr Braga-Mele asked. There have also been reports of cystoid macular edema after FLACS, and this needs further study, she said.

"Femto matches, but currently does not outperform, phaco," she concluded. "But there is increased cost, an increased learning curve, intraoperative issues (including posterior capsular rupture), and postop issues."

She cautioned that a cost–benefit analysis should be conducted before the equipment is purchased.

Laser-assisted surgery is the future, but to make it a more viable option, it will have to cost less and be more efficient, and the machine will have to be smaller, Dr Braga-Mele said.

Audience Weighs In

In the end, the audience, armed with clickers, sided with Dr Braga-Mele, and 83% agreed that FLACS is not worth the extra cost.

The results were not surprising to moderator Randall Olson, MD, director of the Moran Eye Centre at the University of Utah School of Medicine in Salt Lake City, although he said he expected the vote to be closer.

 
The promise is huge, but the actual documented evidence is disappointing. Dr Randall Olson
 

"The promise is huge, but the actual documented evidence is disappointing," he told Medscape Medical News.

He said FLACS is superior in some niche areas, "but for the routine normal cataract, I think it's a very hard case to make that it adds anything other than expense and time."

Phacoemulsification took about 15 years to become the standard of care, Dr Olson explained, adding that for FLACS to become more common, "the price has to come down."

Dr Cionni reports receiving consultant fees from Abbott Medical Optics, Alcon Laboratories, Carl Zeiss, Glaukos Corporation, Mile High Ophthalmics, Morcher GmbH, Ocumetics, Omeros, and ReVision Optics. Dr Braga-Mele reports receiving consultant and lecture fees from Alcon and Allergan and has performed FLACS surgeries. Dr Olson reports holding patents and/or receiving royalties from Mastel and owning equity in XEnd.

American Academy of Ophthalmology (AAO) 2016 Annual Meeting. Presented October 17, 2016.

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