Q: I just got a letter from a local surgeon that he is now doing cataract surgery with the femtosecond laser. Is this a better procedure for my patients?

A: “Yes, it’s better in some ways, but like everything else, there are plusses and minuses,” says Jeffrey Hood, O.D., of Carolina Eyecare Physicians, in Charleston, S.C. “It’s not necessarily for every cataract patient.”

Laser cataract surgery does not replace phacoemulsification. “It does allow the surgeon to fragment the lens with less energy. The capsulorhexis is perfectly circular, centered and reproducible, which helps with refractive outcomes. The cornea wounds are very precise, which may help with the outcomes as well. A big advantage is that it allows the surgeon a better way to fine-tune the astigmatic correction. Overall, it gives the surgeon and the patient more opportunities to have a better refractive outcome.”

For astigmatism control, the femto laser allows the surgeon to place an unopened arcuate in the cornea, Dr. Hood says. Then if the patient needs a postoperative adjustment for residual astigmatism, the surgeon can do it by opening up that arcuate in the exam room at a later time. “Let’s say the patient has 0.50D of post-op astigmatism. Instead of giving the patient glasses, the O.D. can send the patient back to the surgeon, and cylinder can be corrected,” he says.

There are two downsides to laser cataract surgery thus far: one is cosmetic (a minor concern) and one is financial (a major concern).

The cosmetic concern is that patients usually appear with injection and small subconjunctival hemorrhages at the one-day post-op visit. “It’s due to the docking of the instrument against the conjunctiva,” says Dr. Hood. It usually resolves within a few weeks, and it’s nothing to be worried about.
The financial concern is a bigger issue. Medicare reimbursement will not change if the surgical method used includes the laser, Dr. Hood says. It is an out-of-pocket expense that must be part of a premium procedure—in other words, it can be billed with any type of IOL as long as the patient understands that it is for the correction of astigmatism.

Will the patient pay a premium price to “have surgery with the laser,” which may decrease their chances of wearing glasses after cataract surgery? That’s a question that the O.D. can (and should) discuss before the patient is referred.

Specifically, Medicare reimbursement for cataract surgery doesn’t change according to the surgical methods—the reimbursement is the same whether the capsulotomy is made with a cystotome or femto laser. Also, providers may not “balance bill” a Medicare patient for any additional fees to perform the covered components of cataract surgery with a laser.

But, cataract patients can be billed for any additional services used specifically to implant premium refractive IOLs, as well as any associated incremental professional and technical services. However, the patient must consent to the additional out-of-pocket costs in advance.

Q: How will my role change in the pre- and postoperative care?

A: The extra work will be on the front end, to educate the patient about the additional solutions to their wants and needs, Dr. Hood says.

“Patients walk in our door and say, ‘All I know is, I want that laser cataract surgery!’” he explains. “But they don’t know what it does. They don’t even know why they want it.” So the optometrist’s first job is to ground the patient’s expectations. Rather than offering the patient a menu of different procedures and IOLs, doctors should ask cataract patients what their visual goals are, Dr. Hood says.

“A lot of people say, ‘I’ve been wearing glasses for 80 years and I don’t mind wearing them—but I want the laser!’ Well, that patient isn’t a good candidate for the laser because he will not perceive any benefit from the procedure,” he says. “Instead, a patient who is interested in being less dependent on glasses after the procedure, and is willing to pay out-of-pocket to do so, is a better candidate for this premium procedure.”

About 50 of these lasers are now in use in the U.S. So, O.D.s will need to keep informed of ongoing studies to find out if these lasers live up to their prestige and appeal.