EyeWorld Asia-Pacific June 2014 Issue

June 2014 21 EWAP FEAturE Dr. Hoffman said that he currently does not offer femtosecond laser cataract surgery to his patients. However, he would explain the situation to a patient if he or she were interested in the technology. “I would explain that at this time, insurance and Medicare do not cover the laser treatment and due to Medicare regulations, we could not offer it unless they had astigmatism that would be treated at the same time,” he said. “I do not believe that it offers significant enough advantages that there are any ethical concerns about not performing the surgery with the laser if a patient cannot afford it.” Views from Asia-Pacific Laurence SULLIVAN, MBBS, FRANZCO LaserSight and Bayside Eye Specialists 2/100 Victoria Parade, East Melbourne, Victoria 3002, Australia Tel. no. +613-95967440 Fax no. +613-95967449 Laurence.sullivan@gmail.com T he ethical dilemma of continuing to offer mainstream techniques when newer technologies come along is not a new one. In the situation when the newer technology is obviously better and widely acknowledged as so, it can present a dilemma to the clinician who is not offering the new technology. I agree that it is important to discuss this openly and fully with the patient when offering them surgery. I don’t think that dilemma necessarily applies widely with the use of femtosecond lasers in cataract surgery. I disagree with Dr. Banja’s assertion that femtosecond laser cataract surgery is proven to be safer than traditional phacoemulsification. I actually believe that a lot of the claims that have been made for femtosecond laser cataract surgery have not yet been proven in randomized controlled trials reported in the peer reviewed literature. I certainly think ethical difficulties arise when clinicians with consultancies/financial interests associated with the femtosecond laser companies are asked to comment on the technology and I certainly take those comments with a pinch of salt when I read them. I believe the jury is still out on this technology, but do feel that with further refinement of the technology and the indications for its clinical use, that it will find a place in our surgical armamentarium. I currently am a part owner of a femtosecond laser for cataract surgery and an owner of a femtosecond laser for flap making in LASIK refractive surgery. I use the flap making laser routinely, but have only found cause to use the femtosecond laser for cataract infrequently. In 12 months I have done about 10 cases. Editors’ note: Dr. Sullivan is part owner of a femtosecond laser for cataract surgery, a consultant for Zeiss, and inventor and owner of precisioniolguide.com . When patients could benefit but don’t qualify for a femtosecond procedure Dr. Hoffman said that a surgeon may come across an ethical dilemma if a patient could benefit from using the femtosecond laser but it is not indicated based on CMS guidelines. “Ethically, they should perform it and absorb the additional costs,” he said. Dr. Miller said one issue that arises is that under Medicare, you can’t just pay for the femtosecond laser because you want it. “Medicare’s guiding principle is the ‘golden knife’ principle,” he said. “You can’t charge a patient more just because you use a golden knife to make your incisions.” He said that so far, the major benefit that has been seen with the femtosecond laser is safety. Less phaco energy is expected and the capsulorhexis is rounder. But you won’t get paid more for doing a safer procedure, he said. Dr. Banja said there are several fundamental questions about the overall utility of femtosecond laser technology. The physician needs to determine how much benefit should be present to justify using the femto laser versus the manual procedure, what is the actual benefit, and how likely it is that the benefit of the femto laser would be different from a standard procedure. These questions also need certain data and research. “Until we have that data, I think the femto controversy will continue because ophthalmologists will only use their anecdotal experience, what they hear their colleagues saying, and their overall gut reaction to femto,” Dr. Banja said. When physicians don’t provide femto Despite the growing interest in the femtosecond laser, not everyone is using this technology just yet. If the patient is interested in the femtosecond laser but it is not provided by the physician, Dr. Hoffman thinks that it is the physician’s responsibility to explain the possible benefits and additional costs to the patient. If the femtosecond laser is the choice for the surgery, physicians could then suggest a surgeon who is using that technology, he said. “At present, an ethical ophthalmologist can only respond as he or she honestly sees femto playing out,” Dr. Banja said. “If the doctor doesn’t provide femto, he or she should inform the patient of that if the patient requests that technology.” He also noted that if the ophthalmologist believes that femto doesn’t make a significant difference in cataract outcomes or won’t make a significant difference for a given patient, this should be explained to the patient who inquires about it. “The interesting ethical question would be if the ophthalmologist had come to believe that femto outcomes are substantially better than using a freehand technique but he didn’t offer femto,” he said. This could lead to a “struggle of conscience” for the physician who may not be offering what he’s coming to think should be the “standard of care.” What to ethically present Dr. Banja thinks that the best ethical justification for using femtosecond laser technology is if it’s used to foster the patient’s benefit or for the sake of the patient. “Ethical behavior is always other-directed, not selfinterested,” he said. “Consequently, if a physician withholds or distorts a piece of information, it should be for very compelling patient- centered reasons. And even then, the physician should think twice before doing it.” EWAP Editors’ note: Drs. Hoffman, Miller, and Banja have no financial interests related to this article. Contact information Banja: jbanja@emory.edu Hoffman: rshoffman@finemd.com Miller: kmiller@ucla.edu