Informed Consent
Episode 27

The Growing Femtosecond Market

Pulin Shah, MD, joins Marguerite McDonald, MD, FACS, for a deep dive into the topic of femtosecond laser cataract surgery. They discuss the growing market for the surgery, and the ins and outs of its successful implementation.

MARGUERITE: Welcome. I’m Marguerite McDonald of Ophthalmic Consultants of Long Island in Lynbrook, New York, and this episode of the Informed Consent: Getting to Yes, podcast is a little different. I get to dive deeply into a topic with a single guest. That topic is the growing market for and success of femtosecond laser cataract surgery, and my guest is Dr. Pulin Shah, the medical director of Ochsner Baptist LASER Vision Center in New Orleans. Welcome, Pulin.

PULIN: Thanks for having me, Marguerite. It's good to talk to you.

MARGUERITE: Well, Pulin, tell our listeners a little about your practice in my old hunting ground, New Orleans.

PULIN: Yeah, absolutely. So, I work at a large multi-specialty hospital called Ochsner. Our ophthalmology department is about 10 MDs and 13 ODs throughout several different centers. Again, our population of patients is pretty diverse. We take all types of insurance and Medicare and Medicaid and everything else, so, it's a pretty diverse population and a pretty robust volume because of our internal OD network.

We operate in a hospital outpatient surgery center. I'm an employed physician, so it does have those kinds of university/institutional types of barriers that are there for sure as far as access to lots of technicians and stuff. We were limited in what we can do, but even within that environment, again, I think good patient education and explaining things quickly and efficiently to patients can make a big difference in their understanding of the technology and their acceptance of it.

MARGUERITE: When did Ochsner get into femto cataract surgery?

PULIN: We purchased femtosecond laser about 5 or 6 years ago. In those 5 years or so, it's been wildly successful. We did some premium cataract surgeries before then of course without the femtosecond. Once we implemented the femtosecond laser, our conversion to premium surgery doubled very quickly. I think it was mostly because the femtosecond laser. The concept of a laser involved in cataract surgery is one that's very familiar to patients because of all of the other technologies we have because of LASIK and everything else. So, when we use that word and explain how a laser technology can improve outcomes, patients, I think, understand that much easier and they're much more accepting of it because it's just more familiar to them than talking about multifocality or whatever else, or astigmatism management.

MARGUERITE: Does Ochsner package femto with premium IOLs?

PULIN: Yes, we do. The way I explain it to patients is that we can do your surgery in a traditional way, or we can do fancy cataract surgery. Fancy cataract surgery, or what we call laser-assisted cataract surgery, is a whole host of technologies that are basically all designed to give you a better outcome so that you have less dependence on glasses.

I typically try not to go into too much detail about what all those various laser technologies are because we have several different ones. We have different IOL technologies where we're going to combine these laser technologies with lens technologies in order to try and deliver the outcome that you want, whether it's good distance correction or good distance and some reading correction as well.

MARGUERITE: So, you have this wonderful internal OD network. Do you also have outside ODs who refer in?

PULIN: Not for cataract surgery, typically. We have all of our specialties covered, so we get a lot of subspecialty referrals. For routine cataract surgery, it's typically only within our network.

MARGUERITE: Because you are known to have a really great conversion rate, Pulin, would you mind pretending I'm Mrs. Smith and, sort of, now that you've decided I would be a good candidate for femto, and if you want to say femto in a premium IOL?

PULIN: I like to have the information before I enter the room as far as lens calculations, biographies, all the information that I need in order to determine if that patient is going to be anatomically a good patient for premium cataract, make sure the retinas are okay and everything else. So, if the patients were good candidates, again, I'd like to know that going in. If they have a lot of astigmatism, that may limit some of my choices, so I'll get all the measurements and stuff preoperatively.

In addition, we have a patient questionnaire that kind of helps me to specify exactly what the patient's needs and desires are as far as distance and distance and near correction. So, we ask them lifestyle questions about how they want their outcome to be after cataract surgery and is it important for them to be without glasses.

So typically, again, I'll walk into the room and introduce myself and explain a little bit about cataract surgery and then, again, say that there are some decisions that you have to make. We have different technologies that can be utilized for your cataract surgery and some of them require an additional cost, so I want to go over that with you.

Traditional cataract surgery is fully covered by insurance, but most patients still need to wear glasses after traditional cataract surgery. So, if you're interested in being out of glasses or reducing your need for glasses, we have several different options and we package them all. We use the term laser-assisted cataract surgery just to explain all the different technologies that go into that type of procedure. If you choose these options, you have to make a decision whether you want good, uncorrected distance vision. So, you'll see well in the distance, but you'll need reading glasses for anything inside of arm's reach. Or, would you like to see well in a distance and also be able to see things like your computer and your cell phone without always having to wear reading glasses.

So, that's the first thing I kind of say to patients as far as introducing the concept of new technologies that they will have to make a decision about, and then the choices of distance versus distance plus some reading.

MARGUERITE: Great. Do you find that they sometimes are unable to decide, or do most of them say, "Yeah, I want to see at these two distances?”

PULIN: I think most patients kind of say, "Well, of course I want the best," or, "I want to see as much as I can without glasses." Most of them do. But some of them will say, "Yeah, I don't mind wearing reading glasses. I've been doing that forever. I just want to make sure I don't need prescription glasses." So, a lot of it is preference. As I'm doing that, I'll also point and use, kind of, our cost sheet, I guess, in front of them.

In that cost sheet, we have three different options. Actually, we have four different options. I'm trying to limit them to three. I always cross one out, because basically, we have the option that says at the bottom traditional cataract surgery fully covered by insurance. Underneath that, it says most people still need glasses. So, that's option one.

Or, if you are interested in reducing the need for glasses, we have these two other options. If they have a high amount of astigmatism, which I know, then I'll cross out just distance correction without a toric or use a toric. If they have a low amount of astigmatism, I'll cross out the toric. Again, so they have just two options to choose from, either distance or distance with some near correction.

So, as I go over that, I'm showing them the prices as well, because I want them to be aware of cost. There's a fork in the road, and either you go traditional or you're going to go with new technology, laser-assisted cataract surgery. If you choose that path, then it's two other simple choices, distance or distance and near. Kind of breaking it down to those two questions at a time, I think it's easy for patients to get to their choices quickly.

Again, they've already got cost implemented into it, so it's not a surprise at the end of the discussion, “oh well, there's a cost associated with that.” Yes, we like to bring that up at the beginning so that patients understand that from the get-go.

MARGUERITE: Do you ever get people who say, "I want the premium IOL but not the femto," or, "I want the femto but not the premium IOL," where they wanted just to have one or the other?

PULIN: So, we don't offer that as an option, because I think that's tremendously confusing to patients. So again, we don't talk too much in terms of technology, because if I had to explain to everyone what a femtosecond laser is versus an interlocutor lens and the benefits of this lens versus the other, I don't think that patients would understand it. I think it would take me a very long time and I think it adds to confusion.

So rather than talking about technologies in particular, again, we simply talk about outcomes. I tell them I use the word laser-assisted cataract surgery simply as a description of all of these technologies that we put together into a package or we put together into a surgery in order to achieve the outcomes. So, we definitely stay away from talking about technologies, because there are often times where I'll use it or not use the technology on the fly. Our goal is the outcome at the end of the day, and so that's where I focus this discussion. We don't talk about this laser versus that laser or ORA or a multifocal or a toric lens so much as distance correction or distance plus some reading.

MARGUERITE: Like for instance, if it's a package and you get into the OR and they simply won't dilate enough for femto, no worries. It's all part of the package, and you may or may not be able to utilize femto.

PULIN: Right. Something may happen. I may not be able to utilize one technology or the other. So, I want to make sure that I'm not restricted in that and I don't have to feel guilty if I don't have access to a technology or something happens in surgery where I can't do it. I don't feel bad about saying, "Well, OK, we're going to skip that. We're going to use the ORA," or, "We're going to skip that, we're going to use this." I have the flexibility to do that as long as I deliver the outcomes.

At the end of the day, the reality is we're not always 100% perfectly accurate for every procedure. So, I also explain that part of the laser package is our enhancement guarantee or whatever. So that if I get to the point where I can touch things up after surgery, and if our outcome is not quite what we expected, because sometimes it's not, we have the ability to touch it up. So, I use an excimer laser also, and that's included in the package. There are often times where I'll use that laser, and there are times where I will not use that laser.

So, again, there are technologies that I try not to discuss in detail because I think it's confusing. We speak in terms of outcomes. We have the flexibility to use different technologies in order to deliver the outcome. So, the same thing goes with toric versus monofocal lenses. I may anticipate using a monofocal lens, but then intraoperatively my aberrometer tells me I need to put a higher power toric correction in there, so then I'll switch to a toric. I have that flexibility to do that without promising a patient I'm going to be using a toric lens or not. Vice versa, if we're planning on a toric but there's no cylinder on the aberrometry, I may choose to put a monofocal lens. Then again, it's not about the technology we use, it's about the outcome we deliver, and that's my message.

MARGUERITE: I think that's very wise. It sounds like ORA is part of the premium package also.

PULIN: Correct.

MARGUERITE: Do you use ORA on everybody with the premium IOL?

PULIN: I do, and I do because I think that it's nice to's an easy way to track my outcomes. I think that's critically important for surgeons who are embarking on this premium cataract voyage…we have to pay attention to our outcomes. ORA for me, it's just a very simple and quick and efficient software system and everything to help us to track our outcomes, providing information and topically in alignment, especially post-myopic LASIK patients, I think those are situations where I find the aberrometry very helpful.

MARGUERITE: I couldn't agree more. Pulin, I totally agree it's better to talk about outcomes than go off in the weeds. If you go off in the weeds, you're stuck there for 45 minutes.

PULIN: Exactly. Patients don't really get it. It's complicated. What I say is, it's like they're coming to you as the surgeon for your expertise and advice and your recommendation, so, don't push off that responsibility to make a decision 100% on the patient, because they're actually expecting you to help them make that decision. They can tell you what they want. They need you to guide them in how to get there. That's an important message for surgeons and for people getting the premium cataract surgery. Your expertise is important, and your knowledge is critical. They need your input. So, don't feel like, well, I don't want to sell this and so I'm going to push it on the patient to make a decision, because that's what we sometimes do if we’re unfamiliar or insecure about it.

The reality is, you have access to this tremendous amount of technology in the world today in cataract surgery. You pick and choose what you feel like is going to work best for you. When you talk to patients, try not to talk in terms of technology. That's your expertise. They know what they want. They either want to wear glasses after cataract surgery, in which case it's simple, or they want to not wear prescription glasses and maybe they're okay with readers, that's a distance correction, or they want to be as free from glasses as they can at as many different distances as they can. So, if that's the case, then your job is to explain to them how you're going to do it and deliver those outcomes. I don't think they really need to be bogged down with the details. That's your expertise, and you need to be comfortable with the technology that's going to get you there and get them there to that outcome.

MARGUERITE: Pulin, do you find at Ochsner that a fair number of people want to finance it with Alphaeon or CareCredit?

PULIN: Yeah, we do have a fair number that utilize those. CareCredit is the one we use. I think a small percentage of patients do. I would have thought it would be more, but actually most patients can afford it. These are patients in their 60s, 70s. I think a lot of them have saved up money for their health care, and they've planned for this. It's not a huge burden for most of them to do it. If it is, again, we offer that, and we help them out. We have our financial counselors who come and say, "Well, look, we can break it down to 12 interest repayments over a year or 18 months," and that makes it really affordable for most people.

MARGUERITE: I couldn't agree more. Do you ever hand off somebody with significant ocular surface disease to your OD to tune them up and give them back to you?

PULIN: Yeah, we do. I think it's important obviously to do good evaluations for everybody, and part of that for me includes topographies and OCT and good biometry. If in that process we find that it's unreliable or the astigmatism is hard to measure, we look at the department and see if there are signs of ocular surface disease, or like say on exam, we identify that. If there's challenges there, we certainly want to treat those first because, again, we're talking about outcomes. When you're trying to achieve an outcome, you have to know what you're treating. If you don't have good astigmatism measurements because of ocular surface disease, you have to get there first.

MARGUERITE: When you're talking, do you cover any possible glare, halos with multifocal, and EDoF?

PULIN: Absolutely. So, the keys I think to a successful practice and happy patients are communicating openly and honestly about the pluses and minuses of the technology. That's critically important, and you have to be comfortable with that. You have to know what the limitations and what the side effects are of each technology, whether it's LASIK and you're talking to LASIK patient, or it's premium lenses that are multifocal, or an extended depth of focus lens. You need to be comfortable and know what the side effects are and be able to explain that to patients easily.

The way that I do it, I use a couple of techniques in the lane that I think helps explain it to patients. I'm a very visual person, and I think patients are too. So, I have a couple of photographs on my phone that I'll pull up or that I've printed out in examining that show a point source of light that's perfect and then the point source of light with some starbursts and another one with some halos. When I point out those images, I tell them this is an idealized spot of light, which doesn't exist in our world.

When you have a cataract, you typically have a lot of these glare and halo things. When we do your cataract surgery, your vision will be better, and it'll be much clearer and more in focus. There'll be some of these aberrations that are still there, and I point to them. I show them a picture of what we think the glare and halo will be like after. So, it puts an image in their head. I think with the image in their head, they're much more able to accept that possibility and that concept.

I also explain to them that these mild side effects after surgery are typically going to get better with time just like the floaters that you have. If I tell you right now that you have floaters, you start to notice them if you look at a white wall. A minute ago, you didn't notice them, and why does that happen? Because your brain tunes that stuff out; it becomes background noise. In a similar way, when you have some of these mild starbursts or halos around lights, you're going to notice them at the beginning because you just had surgery. Over time, your brain will tune them out, just like they tune out the floaters that you have, and most patients adapt to those things very quickly.

So, those are the words I use. I think it's important again to bring those subjects up so that they're not surprising the patients afterward. I think if you select your patients carefully though, patients with significant cataracts, those side effects with our modern technology are actually much less than they used to be with early generation multifocal lenses, so it's much less of an issue. I think that some surgeons who may have had bad experiences in the past with technology should maybe come back to our modern lenses, because the side effect profile of our current lenses is really, really good, and those side effects are really minimal, but I still think it's important to touch on them.

MARGUERITE: The images on your iPhone that you show them, did you get them off one of the IOL websites?

PULIN: Yeah. I think there's a couple of different tools there. One of them is the IOL Counselor or something. I actually got it from Daniel Chang. I think he did something on his computer with Photoshop or something. He created these images, so I had him just email them to me. I think they are available around, just any image that shows, like, a picture that has some halos around lights or something at night. I mean, any kind of image that you can pick up from somewhere I think is useful. Just again, get patients aware of some of these pictures in their head, just so that they're aware of it and they're not getting surprised by it.

MARGUERITE: With such good pre-op information and evaluation, do you ever find that you're surprised, and you just have to do an IOL exchange?

PULIN: In 10 years of doing this, I've done maybe three or four IOL exchanges on my own patients. So, I think it's very, very rare. Most patients, like I said, with proper selection and having discussions about it, they do great. Again, the older generation multifocals are a little bit more challenging, I think, for patients to accept. In the modern era of extended depth of focus lenses and our current multifocal lenses, it's almost unheard of for me to do an IOL exchange. When needed, I think it's something that we should be comfortable doing. I think it's more common for me to do an IOL exchange for refractive error than it is for intolerance of aberrations.

MARGUERITE: Yes. I couldn't agree more. I've also found that some patients, while they're neuro adapting, if they throw in a drop of Alphagan P before they drive home at night, that will make their pupil 0.25 to 0.5 mm smaller during the day and prevent dilation at night, and that helps them ease into neuro adaptation.

PULIN: Yeah, I think that's a great tip, a great pearl. The Alphagan P is a good one.

MARGUERITE: This has been incredibly helpful for me and for our listeners. I'm sure we've all learned a lot. I certainly have. Pulin, we hope you'll come back and do another episode with us in the near future.

PULIN: Oh, it would be my pleasure, Marguerite. Thanks so much.

8/30/2019 | 20:53

More Episodes: