In the summer CEC newsletter, I wrote an article summarizing the laser phacoemulsification (cataract) femtosecond marketplace.  I concluded at the end of the newsletter, that the present units in the field, really provided an advantage to two subsets of surgeons; those looking for a marketing edge over their competitiors  (touting the superiority and less invasive nature of the laser) and those inexperienced or less competent surgeons looking for assistance with certain parts of the phacoemulsification cataract removal.  Since that article was sent and more cases of laser phaco have been performed, surgeons and observers have reported the following: 1) the logistics are not simple as the patient needs treatment with the phaco laser to make the incisions, perform a limbal relaxing incision (LRI) if needed, do the capsulorhexis, and soften the cataract. The patient then proceeds to the OR (if laser phaco performed in another room or location) and under sterile conditions has the incisions opened , the cataract removed and the IOL placed. The logistics and patient flow can be problematic to busy surgeons and some facilities are having different surgeons performing different parts of the surgery. There have been cases with laser phaco leading to radial and stray peripheral tears in the anterior capsule and there have been cases of cataracts that have dropped into the vitreous because of the above issues. Some surgeons have reported more predictable results with the laser phaco when performing limbal relaxing incisions (LRIs). This makes sense as the laser phaco incision depth is more accurate and reproducible. It is unclear whether the more predictable capsulorhexis that is generated with the laser will lead to a more predictable IOL position in the capsular bag, and consequently a more predictable refractice outcome.  Some surgeons are saying the laser doesn't lead to any more predictable effective lens position (ELP) than that obtained with conventional non-laser technology.

  Recently, the American Academy of Ophthalmology (AAO) and the American Society of Cataract and Refractive Surgery (ASCRS) came out with a joint position paper on laser femtosecond phaco surgery and its use in Medicare patients. This paper was the joint effort of health care attorneys, ophthalmic practice and billing consultants to provide guidance to ophthalmologists in regards to what situations patients can be balance billed (charged above and beyond what their Medicare insurance covers). It is important to realize that the position paper refers to Medicare patients only.   However, since non-Medicare insurance policies often follow Medicare guidelines and fee structures, it may also apply to other carriers.  The joint position paper concluded doctors could not charge extra for the femto laser cataract surgery if used with a standard or a premium IOL without LRIs (toric or presbyopic IOL). The doctor could charge the patient for the femto laser ONLY if used for LRIs or for a non-covered refractive lens exchange (RLE). The implications of this position paper are sobering and concerning to those surgeons considering the purchase of such a device.The patient population they will be able to balance bill for the use of the laser femtosecond phaco equipment is extremely limited and will make it extremely hard to impossible to pay for the the large initial capital costs (about 500,000 dollars) per patient click fees (about 400-500 dollrs/eye) ,maintenance costs, etc. The use of the laser to do simple LRIs in a cataract patient without a presbyopic IOL is a nonstarter also, given the more accurate neutralization of astigmatism with the toric IOL.

  At a recent meeting I attended in Arizona, some of the panelists who have the femtosecond phaco laser described how they are placing femtosecond incisions in the steeper meridian of essentially ALL their cataract patients.  Postoperatively, they selectively open the incisions to titrate and neutralize the existing cylinder. The maneuver cleverly allows the surgeons in their minds to justify that they indeed performed femtosecond LRIs and can bill for the service (as delineated in the joint paper described earlier).  Many of these femtosecond LRI applications will never be opened and the intent of the surgeon is quite clear; to try to justify the use of a machine that is not needed in many cases.  It is just a matter of time until CMS and the OIG catch on to this abuse and start to conduct audits of doctors that have performed the cataract surgery and been involved in the patients aftercare.  If you are comanaging these cases, caveat-emptor!  

  The technology will keep evolving (become less expensive) and treatment algorithms will become safer for our patients. A growing number of surgeons feel corporate interests have hijacked our ophthalmic leadership and are trying to pull our profession in a direction that saves them from their own poorly advised investment. In time, we will better understand what role, if any, this technology will play. At CEC, we are patient advocates and look for technology that provides the patient with better outcomes, not technology that doctors can use to confuse and mislead the public. In our opinion, the later exists presently. We will continue to closely follow the technology and keep you updated.   

JOHN C BALDINGER MD

   A recent article in the Feb13 issue of the Archives of Ophthalmology concluded that laser trabeculoplasty and topical prostaglandin analogs both appear to be cost-effective options for managing open-angle glaucoma (OAG). A Markov mathematical model with a 25 year time horizon to compare the cost effectiveness of prostaglandin analogs (PGAs) vs laser trabeculoplasty (LTP) in treating patients with newly diagnosed mild OAG was utilized. The researchers also found that laser trabeculoplasty may be the better choice in patients at risk for poor medication adherence. 

  Our experience at CEC with our in-house Selective Laser Trabeculoplasty (SLT) unit has been very positive. We

have had a high level of success (defined as amount of IOP lowering and response rate) in the patients we have treated since purchasing the Lumenis laser several months ago.  The procedure is quick and essentially painless for the patient. We also have found SLT to be very useful in patients that have topical hypersentivity to glaucoma drops, are non-compliant, or don't want the inconvenience and/or expense of drop therapy.

  CEC has a new automated answering machine to take a little of the burden off of our front office staff.  We think it is pretty user friendly. To increase its friendliness factor for referring doctors, we have given you your own designated prompt. When calling us push the #9 prompt and someone will pick up in short order.