In this episode of Interventional Mindset, Drs. Keith A. Walter and Gary Wörtz discuss how to initiate implementing femtosecond refractive cataract surgery into practice and what the procedure has to offer to patients and ophthalmologists.
Interventional Mindset is an educational series that gives eye physicians the needed knowledge, edge, and confidence in mastering new technology to grow their practices and provide the highest level of patient care. Our focus is to reduce frustrations associated with adopting new technology by building confidence in your skills to drive transformation.
Browse through our videos on a variety of topics within cataract and refractive surgery, glaucoma, and ocular surface disease to learn practical insights into adopting a variety of new surgical techniques and technology.
An introduction to femtosecond laser cataract surgery
As a professor of ophthalmology and laser in situ keratomileusis (LASIK) surgeon at Wake Forest Baptist Health Eye Center, Dr. Walter explained that 7 or 8 years ago they began adopting the femtosecond laser for cataract surgery when it was still considered new. Fast forward to now, he performs femtosecond refractive cataract surgery on around 70% of his cataract patients to improve their distance vision.
He added that as a LASIK surgeon, his mindset to treating patients is to get them as close as possible to a plano outcome following cataract surgery. However, at the time, before the femtosecond laser was available, surgeons could only rely on strong biometry and limbal relaxing incisions (LRIs).
In his professional medical opinion, a recurring problem with performing LRIs is that there can be too many variables. He mentioned every cornea is a different diameter, which could cause variability in results, and because the incision is at the limbus, the wound tends to heal more and potentially regress. Conversely, even just for reducing astigmatism, a laser can consistently, safely, and effectively hit the necessary 80% depth to perform the procedure.
The femtosecond laser adds a level of precision to refractive cataract surgery that allows surgeons to target lower levels of astigmatism and better correct vision, highlighted by Dr. Wörtz.
Filling the gap of patients with astigmatism seeking distance vision
Dr. Wörtz then mentioned a study that he led with Preeya K. Gupta, MD, on the value of using femtosecond laser arcuate incisions in patients with low corneal astigmatism. These patients tended to not have enough cylinder to qualify them for a toric intraocular lens (IOL), but they had enough astigmatism that they required treatment. He explained that these particular patients are good candidates for a femtosecond laser procedure.
The femtosecond laser has expanded the patient population that he can treat with multifocal IOLs and patients who want clear distance vision, added Dr. Wörtz, because he is able to deliver a higher level of precision and better outcomes. Additionally, he mentioned that in his practice, over 50% of their patients have less than 1 diopter of astigmatism going into cataract surgery, so a large portion of his patients could benefit from having their astigmatism reduced with a femtosecond laser.
Dr. Walter explained that adopting a femtosecond laser has helped him become a better cataract surgeon and also improved his refractive surgery with cataract patients. This is a value-added service, with an outcome that will likely be difficult to attain with a manual procedure, he remarked.
Discussing femto refractive cataract surgery with patients
When explaining this procedure to patients, Dr. Walter explains to them that correcting astigmatism is a non-covered service under Medicare guidelines. Instead, Medicare’s preference has historically been to pay for the service in the form of coverage for glasses since patients can get one free pair after cataract surgery. However, in the long run, the patient could benefit from having their astigmatism treated upfront to possibly reduce the need for purchasing glasses on a semi-regular basis.
He mentioned a study from Daniel Chang, MD, in regards to the risks associated with bifocal glasses, including a 2.3 times higher chance of older adults with multifocal glasses falling compared to those in single-vision or no glasses. As such, Dr. Walter mentioned that even using a femtosecond laser procedure to get patients from bifocal glasses to reading glasses—which are more accessible and economical— confers great value to patients, in his opinion.
In response, Dr. Wörtz highlighted that he thinks it is important to discuss the full range of possibilities that new technologies offer patients when it comes to vision correction and not make assumptions about what the patient is interested in or may want to pursue. Part of the responsibility of the surgeon is to use their expertise to outline the different opportunities available to patients with evolving technology, and empower them to make informed decisions.
He added that it is helpful to ask patients what their vision goals and needs are in order to hone in on what type of procedure would be the best fit. To contextualize the out-of-pocket cost of the procedure, he often tells patients that investing in their vision is one of the few expenses they can put money towards that will benefit them every day for the rest of their lives.
Potential limitations to femtosecond refractive cataract surgery
Dr. Wörtz noted that generally, adding a femtosecond laser to cataract surgery adds around 1.5 minutes to the procedure. Dr. Walter performs the surgery slightly differently because he utilizes a main incision, which tends to add another 7 to 8 seconds, still ensuring that the procedure is less than 2 minutes long in total with a large lens and a wide, dilated pupil.
While some clinicians have raised concerns that femto slows down the surgeon when performing cataract surgery, Dr. Wörtz reflected on the fact that there is a great value added to the patient with the additional—and still relatively short—time needed to perform the procedure. He concluded that the slowdown is well worth it.
Similarly for Dr. Walter, on a surgery day, he tends to perform around 15 cataract surgeries, 10 of which are femtosecond laser-assisted surgeries. Because there is one room that he operates out of, there is about a 5-minute turnover between surgeries, which gives him the time to comfortably add a femtosecond laser procedure on a busy surgery day.
Final thoughts
For anyone who is considering starting a refractive cataract surgery program, Dr. Wörtz encouraged them to begin with a femtosecond laser and add toric and multifocal IOLs as second and third options.
He recommended this because using a femtosecond laser is intuitive, and the learning curve is short, so there is a relatively low threshold to add a powerful tool for reducing astigmatism to their surgical armamentarium.
With constantly evolving technology, it has become much easier for surgeons to treat patients with the latest technology and to provide them with an enhanced surgical outcome built around their visual goals and needs.
