EyeWorld Asia-Pacific March 2013 Issue

30 EWAP CATARACT/IOL March 2013 The business side of femto for cataract by Michelle Dalton EyeWorld Contributing Writer Efficacy and safety issues aside, practices debating how to integrate a femto- second laser and when to use it should read on W hen evaluating whether or not to purchase a femtosecond laser for refractive cataract surgery, the question is not whether or not the technology is viable, but how to bring a very expensive and space- consuming piece of equipment into the surgical area without disrupting patient workflow. Leading authorities tell EyeWorld how they went about it. Physical placement Physically smaller practices—those with one or two ORs—that have dedicated refractive and cataract suites have an advantage over a general teaching hospital where the OR is used by various specialties, said Kevin M. Miller, MD , Kolokotrones Professor of Clinical Ophthalmology, Jules Stein Eye Institute, Los Angeles, Calif., USA. Ambulatory surgery centers (ASCs) with three or four rooms, however, have a harder situation “because you might have two doctors doing cataract surgery on a given day, and you’re probably not going to buy one femto laser for each room,” Dr. Miller said, adding some bigger facilities are “just finding a closet where they can place it.” The dilemma for ASCs is that most haven’t been built with enough physical space to house the laser and may end up placing it on another floor altogether, said Robert P. Rivera, MD , in private practice, Hoopes Vision, Draper, Utah, USA. His group was already scheduled to move into a new facility at the end of last year, so they reconfigured the space to accommodate the two femtosecond lasers the ASC uses into their own dedicated room. For Robert J. Weinstock, MD , in private practice, the Eye Institute of West Florida, Largo, Fla., USA, there were already four ORs and a good amount of pre-op and post-op space, “but what we didn’t have is a lot of ‘extra procedures’ room. In one small room we have a YAG laser and an argon laser, but no room to house more.” The group weighed several options, including “stealing” a conference room, or taking some space away from the kitchen and other administrative areas. They decided to place the laser in one of the ORs and drop down to three rooms for intraocular surgery. At the Center for Sight, Sarasota, Fla., William Soscia, MD , said four of the surgeons are cataract specialists, and the entire ASC is “very high volume”. The group spent almost two years evaluating how to incorporate the technology into the available space and ultimately opted to build a separate room, complete with an observation area for family to watch while staff members narrate the entire femtosecond aspect of the procedure. Dr. Miller said “moving 80- and 90-year-olds around is no simple matter,” but at Jules Stein the only place to put the femto laser was on a different floor from the surgical suite, and that with 10 surgeons vying to use the laser, “it’s going to be a total nightmare.” Impacting the workflow The Catalys (OptiMedica, Sunnyvale, Calif., USA) is the only one of the devices where patients can have the femto portion done on the same bed as their cataract removal, Dr. Rivera said. From a patient perspective, that’s the least disruptive, he said, but not all machines are capable of that just yet. “Ergonomically, we had to decide what would make the most sense,” Dr. Rivera said. “The downside to that scenario is that it does commit that room to only the surgeons who are going to use the Catalys. That only works in a situation with dedicated anterior segment surgeons.” The logistics of scheduling several surgeons when the femto resides alongside a phaco machine is daunting, Dr. Miller said, but it’s equally difficult when the femto is in a separate location. “It’s now going to take a procedure that takes, say, 20 to 25 minutes in an average person’s hands, or 10 minutes for somebody who’s really fast, and make it at least twice as long, if not three times as long, if the laser is outside the room,” Dr. Miller said. With reimbursement rates declining, losing time on one patient because of logistics can be economically devastating. Workflow can be difficult in very high volume practices, Dr. Soscia said. “Before we had the LensAR [Orlando, Fla.] in our practice, we analyzed how to incorporate it—we started focus groups from patients to gauge interest, we evaluated where to physically place it, we looked at staffing issues, and then we tackled how we were going to market this to our patient base.” Dr. Weinstock’s group, “a relatively high-efficiency, high-volume center, where we like to do somewhere At Hoopes Vision, two different femtosecond lasers reside in a previously underused OR. Source: Robert Rivera, MD continued on page 32