EyeWorld India March 2012 Issue

March 2012 12 EW FEATURE Tel: +65 64936953 Fax: +65 64936955 EyeWorld - from page 11 now routinely apply dilators right after laser treatment and inject intracameral epinephrine during the phaco procedure if needed. GB: The suggestion that one could split the operation into someone doing femto and someone else doing the phaco operation radically alters the procedure. KPR: We placed the machine in a different room altogether from day one. For my very first 100 cases, I alone did both parts of the procedure. Afterwards, I’ve had one of the surgeons do the femto procedure while I do all the phaco and sometimes I do the femto for other surgeons. GB: This is fascinating and challenges me. I don’t trust someone else to do a block for me, let alone an entire phase of the procedure. KPR: I wouldn’t let anyone else do a block for me, either, I can’t explain it, it’s like a phobia. But there is something inherently different about this. After the first few cases, I’m sure you will learn to trust someone else to perform the femto for you. CSP: I think my operating theater would be a mess; it would be chaotic! For his setup, Dr. Reddy walks his patients across the corridor, as the rooms are almost door to door opposite one another across a narrow corridor. For us, if we were to have the femto-cataract machine in a particular operating room, then I would have to move my patients from that room to the operating room. Do we wheel them in? Shall we put them on a trolley? All these considerations, including the manpower needed to shift them from one part of the operating theater to another—the logistics involved really perplex me! GB: In my opinion, if this procedure does prove to be safer and more predictable, then regardless of the price, we will use this technology widely, and the price will come down. On the other hand, if we can’t objectively show an improvement over the current cataract procedure, and ‘better, safer, more efficient’ doesn’t actually prove to be the case, it could remain a niche procedure. You would have to profile femto-cataract surgery at this stage as industry-driven technology—we’re all desperate to try it, but it’s really on the cutting edge. Which way do you think this is going to go? CSP: Having spoken to industry, I am told that even with large volume demands for this machine, because it is very costly to build a laser machine, the price can hardly drop. Maybe they’ll find some way to reduce the cost, with market competition and other factors. I really don’t know, but if we can scientifically show that femto-cataract is definitely better, then as IOL technology evolves and improves—this is sure to be the perfect technology, for instance, for creating even smaller incisions for lens refilling technology. Then I feel certain that this is the way to go. I think that in the next 5 years, with more widespread acceptance in developed countries, worldwide acceptance of this technology will be at about 20%. CE: I’m going to slightly disagree with you on the marketing issue. Yes, there is some marketing involved, but I think it’s easier for the surgeons to accept this particular machine precisely because of the predictability and the consistency of what it’s doing— the incisions, the rhexis, and the nuclear fragmentation—without really depending on anything manual, without succumbing to the variations in your technique. Banking on the economics of scale—with more production, more competition on the market, the cost should go down, we just don’t know by how much; as far as acceptance, I think it’s there. I expect almost 50% of surgeons will have femto laser cataract surgery in their practice in the next 5 years; I’m sure more than 50% will want it. KPR: I’ve been associated with excimer lasers in England since ’91, then I came back to India in ’96, and naturally I wanted to put the first machine there. At the time the machine cost US$750,000, and I bought it. Today we have 15 machines. Even though doctors do talk about price, when I buy it, the other guy buys it, and the other guy buys it, we need to provide service and the latest technology; and if our patients think we are providing lesser service than the other guy, we have to buy, and we do buy it. Price matters like that, it’s nothing new or unique to femto lasers—when we bought excimer lasers, they were really expensive, it wasn’t that they were cheap; we bought them because we love technology, we’re all driven by that—some of us more than others, no doubt. But it’s not going to stop. There are all kinds of marketing forces acting on us as doctors, so I foresee more than 50% of people are going to go for this technology. And then when it comes to the actual pricing, obviously we can’t afford anything unless our patients are willing to accept this technology at a price. Most of your patients come to you because you are Graham Barrett, you are Chee Soon Phaik, you are Cesar Espiritu; in my region, people trust me for what I do. I think we can easily sell this procedure to people, provided we believe it is safe, we believe it is accurate, and we believe it has a clinical role. That is the goal: Once we believed that the excimer laser was good and safe, we did PRKs and moved on to LASIK; similarly, once that hurdle in our mind is crossed, more than 50% of surgeons will take note of it and go for this novel technology. GB: So there are many forces at work, and marketing is one aspect. I think once we as surgeons are convinced of the benefits, the patients will select femto because they trust us. If we truly believe this provides benefits and a superior outcome, we’ll be well beyond 50% usage in 5 years. The hurdle isn’t convincing patients, but proving the clinical benefits of this technology. We’re in that process now, and I hope this roundtable will help as part of that process. And with that I would like to conclude this roundtable. Thank you all for a wonderful discussion on all aspects of femtosecond cataract surgery technology. EW