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    Femtosecond laser-assisted cataract surgery: How far have we come?

    Expert surgeons highlight benefits, share pearls offer ideas for advancing the field



    Financial feasibility

    The ability of manufacturers to undertake future developments of FS lasers for cataract surgery will depend on increased use to drive profitability. Achieving the necessary level of uptake in the UK will require integrating FLACS into the public health sector, said Dr David O’Brart, St. Thomas’ Hospital, London.

    Recognising the current financial obstacles to laser installation at NHS facilities, Dr O’Brart and colleagues conducted a time and motion study of high-volume cataract surgery comparing FLACS and conventional phacoemulsification. The aim was to determine if a “hub-and-spoke” model for FLACS could improve surgical throughput and make it more economically viable.

    In the hub-and-spoke model, the FS laser portion of the procedure is performed by a trained ophthalmic nurse or technician in a dedicated room (the hub). Patients are then fed into the operating rooms (ORs, the spokes).


    Results of a randomised controlled, real-world study in which the ophthalmologists-in-training were doing the surgery showed that FLACS significantly reduced the average total time spent in the OR by about 3 minutes compared with conventional phacoemulsifcation.


    “This is the first evidence that the FS laser pretreatment can reduce the duration of the operation,” Dr O’Brart said. However, this study used a 1:2 hub and spoke model and the average overall cost per case was about ₤150 higher for the FLACS procedure.

    A sensitivity analysis was performed to see if modifications of the hub:spoke ratio and cost of the patient interface could reduce the cost of FLACS so that it would be more competitive with conventional surgery. The analysis showed that the parameters at which FLACS could approach this breakeven point might be unrealistic. They involved a 1:4 hub and spoke model, an annual volume per centre of 6,000 surgeries, and discounting the patient interface cost about ₤30.


    “In the real world where there is a finite amount of money available, the administrators who control spending would not agree to purchase the lasers unless there is proof that the results of FLACS are much better than conventional surgery,” Dr O’Brart said.


    Experience in the Netherlands supports Dr O’Brart’s conclusion. Dr Frank Kerkhoff from Maxima Medical Centre, Eindhoven Area, the Netherlands, told how an effort to obtain approval for purchase of an FS laser at the public hospital where he operates proved fruitless after the National Health Institute decided not to provide full reimbursement for such cases because there was insufficient evidence to show it added value.


    “Thus, we have decided to use the laser only for complicated cases where we feel use of the laser increases safety,” Dr Kerkhoff said.


    Dr O’Brart suggested that one way to bring the FS laser into broader use would be if the equipment manufacturers developed and funded surgical centres for the procedures.


    Dr Pitalia stated that such “mega centres” could succeed in metropolitan areas, but may not be viable in less densely populated regions considering that patients do not want to travel far for their surgery.


    Other participants, however, saw the potential for such a change coming in a world where cataract surgery will become even more automated and performed by a dedicated subspecialty group of surgeons.

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