Michael J Kutryb, MD  

Specialties: Ophthalmology, Cataract Surgery, glaucoma

Interests: Ophthalmology
Kutryb Eye Institute - Titusville
Titusville, FL
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Femtosecond Laser Cataract Machines Create More Questions Than Answers

Oct 28, 2011 - 0 comments

     I had a chance to personally view the femtosecond cataract laser systems at the American Academy of Ophthalmology meeting this week in Orlando and I have to say that these systems are quite impressive.  Unfortunately, I have already been wowed in the past by the excimer laser systems that are used for Lasik and PRK surgery.  The new "femto" laser systems look like a small SmartCar in size with large touchscreen LCD monitors for the surgeon and technician to control and view the surgery.  A 3-D computer model of the eye is obtained and a computer-driven laser program has the ability to perform the incisions, the capsulorhexis (the opening into the cataract capsule) and fragment the cataract into segments.
     The femto lasers can do the same steps that a cataract surgeon usually does by hand, but they can do it more precisely.  For example, the surgical incision is typically done with a steel or diamond scalpel precisely sized at anywhere from 1.8 to 3.0 mm.  It takes the surgeon about 3 seconds to make the incision manually, while the femto laser takes around a minute, but it is a perfect incision essentially every time.  Opening up the cataract capsule is a step called capsulorhexis, and it is this step where the femto lasers have claimed clear dominance, demonstrating a superior ability to create a consistently nearly perfect opening in size and shape.  
     Experienced surgeons can still do a very good job at the capsulorhexis, but can't compete in consistancy over hundreds and hundreds of cases.  Questions start to pop up however, because early studies have shown that the improved opening made by the laser makes only a smallish improvement in overall refractive outcomes after cataract surgery and no clear improvement in safety.   Note that a surgeon can make the opening in a minute or less while the laser adds at least 15 minutes to the overall cataract surgery time. Is it worth the extra cost and increasing surgery times up to fourfold?  Remember, the femto laser procedure still requires the surgeon to use traditional phacoemulsification (a finely tuned ultrasonic handpiece) to remove the actual cataract.
     Lasers have so many possible applications but at what cost?  At what point do we go for our bagels being sliced by a laser or laser haircuts or manicures.  We could even have our lawns cut by a laser (maybe at Pebble Beach.)  At present, it is still too early to find consensus that the femto procedure is any better or safer than traditional cataract surgery.  There are some hints that it might be, but as they say, the jury is still out.  From a purely cost/benefit analysis, the extra cost may not be worth it for the average patient. Insurance plans and medicare, clearly are not going to cover any of the cost of the procedure, so patients will have to fork over one or two thousand dollars per eye for the upgrade.  In fact, one of the ironies of the possible femto revolution, is that the patients with the very advanced, complicated cataracts that might benefit most by the surgery, are likely to be the ones least able to afford a large cash-pay upgrade.  Stay tuned for a blitz of marketing from the few very wealthy or ambitious cataract centers that jump on the bandwagon early.  The pricing structure still remains murky.
     I just read an article about how retailers like Sears work very hard to create a tiered pricing structure for products with "Good", "Better", and "Best" products.  They find that a consistent number of customers will generally pick the certain percentage of each.  Often the Best (and most expensive) product serves another purpose, and that is to create interest in the Better (medium cost) product.  I'm sure you will see femto centers  will also have a lower priced, yet attractive non-laser alternative, so they are able to appeal to more patients.

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