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Is Laser-Assisted Cataract Surgery
Worth the Risk?

A commonly accepted rule-of-thumb among surgeons is that additional risk must be balanced by additional benefit to the patient. But, what benefit does the patient get for the potentially high price of added risk? Seemingly nothing other than a lot of hyperbole, vacuous promises of “greater precision”, and disingenuous suggestions that Femto Laser-Assisted Cataract Surgery is necessary in order to get the full benefit of “premium” IOLs.

Because of this combination of added risk without clear benefit to the patient, more than a few eye surgeons (myself included) now believe that charging patients for laser-assisted cataract surgery is not only unjustified, but potentially unethical. Medicine needs new technologies, and the benefit may not always be apparent early on in the adoption phase. That’s generally accepted in medical circles. Forcing patients to pay substantial amounts of money for unproven technology, on the other hand…

When You Opt for Laser-Assisted Cataract Surgery

What, Exactly, Are You Paying for?

Laser-assisted cataract surgery costs hundreds to thousands of dollars more than cataract surgery done without a laser. Given the lack of proven benefit, what are your really getting for this extra fee?

First, why don’t we look at what Medicare (the largest payer of cataract surgery) says about this (you don’t really have to read this as it’s boring and I’m going to summarize it below). I’ve added emphasis to the key parts:

Medicare Part B covers the cataract surgery and the implantation of a conventional lens without regard to the technology used. Revised November 2012 Femtosecond Laser Guidance Imaging performed as part of the FS laser surgery, which is necessary to implant premium refractive IOLs, is considered a non-covered service as long as these services are not used routinely when implanting conventional IOLs. A separate charge for the imaging is allowed with that consideration. However, as set forth above, Medicare Part B covers the cataract surgery without regard to the technology used. The Medicare beneficiary receiving a premium refractive IOL may be charged for non-covered services (such as imaging), but not for using the FS laser to perform covered steps of cataract surgery, such as the phaco incision, capsulotomy, and lens fragmentation.

What?!

Translation: If you are a Medicare beneficiary you cannot legally be charged an extra fee for laser cataract surgery unless you have astigmatism or are opting for a “premium” or “refractive” intraocular lens (IOL) such as a multifocal IOL or “pseudoaccommodating” IOL (such as the Crystalens). You see, the Femto laser falls under Medicare’s “Golden Scapel” rule. It doesn’t matter whether a surgeon uses a metal, diamond, gold, or laser to perform surgery – unless something other than standard cataract surgery is done the surgeon or surgery center cannot charge Medicare patients an additional fee.

Correction of astigmatism or placement of “premium IOLs”, however, is considered refractive surgery. So long as refractive surgery is also being performed during cataract surgery then Medicare allows an extra fee to be charged to the patient.

“But,” you ask, “is the laser required for placement of a “premium” IOL or correction of astigmatism?”

The answer may surprise you: 

No.

Laser-Assisted Cataract Surgery

Why Pay More?

So, why would anyone choose to pay more and undergo additional risk just to have their cataract surgery assisted by a laser? There must be scientific studies to prove that it is a safer and more reliable method of removing a cataract, right?

Wrong! (scroll up to “Is Laser-Assisted Cataract Surgery Better than Surgery Done without a Laser?”)

Sadly, it’s the same reason people choose to pay more for one consumer brand over another…marketing.

Millions of dollars have been spent by the manufacturers of Femto lasers to convince both doctors and their patients that laser-assisted cataract surgery is superior to cataract surgery performed without a laser. The industry has tried everything from intimate dinners at expensive restaurants to rock concert like presentations with laser light shows and loud music (I’m not kidding) to sway the views of eye doctors. Many have been impressed enough by these presentations to spend up to a half million dollars to purchase one of these Femto laser units. Yes, that’s up to $500,000 just to purchase the laser. On top of that the laser companies charge another $300-800 each time the laser is used on a patient.

Think someone who just spent a half million dollars might be just a little incentivized to recommend laser cataract surgery to his or her patients? “Just saying…”

But let’s say you’ve got a few thousand extra dollars burning a hole in your pocket. Should you go ahead and have laser-assisted cataract surgery just for braggin’ rights? I suppose you could. After all, spending hundreds to thousands of dollars to have Femto laser-assisted cataract surgery (which takes longer to perform than cataract surgery without laser use and has no convincing evidence that the final vision will be any better) is a bold statement that “I have money to burn”

Or, perhaps you’re a base-jumper and just like to take unnecessary risks?

But for my money and knowing my patients (who generally think taking unnecessary risk or throwing money away should be avoided, not bragged about), I think there’s more benefit and bragging rights to be had by spending those funds on a vibrant new 70” 4K flat screen TV like this one:

70” 4K flat screen TV

With your post-cataract surgery crystal-clear vision (which may be more likely without the use of the laser) you will now be able to enjoy the subtle beauty of this high-definition display as well as have something substantial to brag about.

Considering Laser Cataract Surgery?

Popcorn anyone?

By the way, you can make popcorn with a laser too.  “But,” you say, “that would take longer than using the microwave and I don’t think the popcorn would taste any better – so why would I want to use a laser to make popcorn?”

Sounds familiar?  Why indeed?

Manual Cataract Surgery Testimonials 

Dr. David Richardson has performed thousands of cataract surgeries without the need for laser assistance. Although he finds Femto technology to be interesting he is far from convinced that there is any real benefit to his patients. As such, he has chosen not to recommend this technology to his patients who need cataract surgery.

“…So, here I am in my 70’s and I’m seeing better than when I was a small child…I wanted the best so I was willing to pay for it without the insurance…

Ron

“…He gave me plenty of time to think of more questions to ask. He’s never been in a hurry. Just who he is has helped me psychologically, immensely, face all this…”

Jane 

“…I feel like he listens to me. and I feel like he cares and I feel like the staff is very receptive to my needs. So, I couldn’t be happier…”

Pam

“…I don’t think I would have been able to pass the vision test for continuing to drive but as soon as I had the surgery, I passed the vision test with no problem… “

Steven

OMG!!!! Everything is so beautiful!!!! The whites!!! Everything so sharp and clear!!!! The colors. The plants, the sky, the outside is so beautiful!!!! I never thought I could see like this!!!
Dorothy Richardson

Dr. Richardson is a true “family doctor”. He has performed successful cataract surgery on his grandmother, mother, mother-in-law, and father-in-law (his own Dad does not yet need cataract surgery)

On Photo: Dr. Richardson, his mother ?, his nurse Ana, and the OR staff at San Gabriel Valley Medical Center after implanting the AMO Symfony Extended Depth of Focus (EDOF) Intraocular lens (IOL).

Hello, look who is back at work. We are all very grateful with the whole staff that works at San Marino Eye, thank you for your attentions, hospitality and good work. Hopefully we will see you all soon either in Los Angeles or in Honduras?…

The Barahona Family

“What a privilege to treat Dr. Aristides Barahona, a well respected and loved general surgeon from Honduras! He flew out to have me perform both cataract surgery and canaloplasty. Here we are smiling together in appreciation of his improved vision and pressure just prior to his traveling back home where I know he has many of his own patients anxious for his return.” — Dr. Richardson

Look! Dr. Barahona is already back to work after a successful canaloplasty surgery for his glaucoma! The family sent us this photo with this lovely note.

For inquiries or to set up a consultation, don’t hesitate to
call at (626) 289-7856 or send a message:

References:
  1. Schultz T, Joachim SC, Stellbogen M, Dick HB. Prostaglandin release during femtosecond laser-assisted cataract surgery: main inducer. J Refract Surg. 2015;31(2):78-81.
  2. Bala C, Xia Y, Meades K. Electron microscopy of laser capsulotomy edge: Interplatform comparison. J Cataract Refract Surg. 2014;40(8):1382-1389.
  3. Abell RG, Davies PEJ, Phelan D, Goemann K, McPherson ZE, Vote BJ. Laser-assisted cataract surgery. Ophthalmology. 2014;121:17-24.

More Studies and Information About FLACS and Manual Cataract Surgery:
  1. 7 Lies You’ve Been Told About Laser Cataract Surgery. [About-Eyes.com]
  2. Femtosecond Laser Assisted Cataract Surgery (FLACS) [About-Eyes.com]
  3. Dry Eye Worse after Laser-Assisted Cataract Surgery [About-Eyes.com]
  4. Femtosecond laser–assisted cataract surgery versus standard phacoemulsification cataract surgery: Study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. [ncbi.nlm.nih.gov]
  5. Benefits and Harms of Femtosecond Laser Assisted Cataract Surgery: A Systematic Review. [hsrd.research.va.gov 
  6. Laser-assisted cataract surgery Why not femto? [eyeworld.org]
  7. Femto Laser Cataract: Avoiding Complications. [reviewofophthalmology.com]
  8. ESCRS FLACS study update: More postop complications with femto than phaco [Healio.com]
  9. Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery [Cochrane Eyes and Vision Group]
  10. Is laser cataract surgery worth it? [www.abc.net.au]
  11. Get the Facts about Laser Cataract Surgery [ecof.com]
  12. Is Laser Cataract Surgery better than tradional Microincision Cataract Surgery? – Dr. Samina [YouTube]
  13. Is it Time for Laser Capsulotomy to Take Center Stage? [crstodayeurope.com]
  14. Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery [http://www.aaojournal.org]
  15. Comparative Review of Capsular Integrity After Femtosecond Laser Cataract Surgery [eyetube.net]
  16. Laser, Manual Cataract Surgery Equivalent [medscape.com]
  17. Does FLACS cost, benefit outweigh manual? No! [ophthalmologytimes.modernmedicine.com]

Get In Touch

Dr. David Richardson has performed thousands of cataract surgeries without the need for laser assistance. Although he finds Femto technology to be interesting he is far from convinced that there is any real benefit to his patients. As such, he has chosen not to recommend this technology to his patients who need cataract surgery.

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