The Journey to Femtosecond Laser-assisted Cataract Surgery
Despite its perceived benefits, FLACS is not yet widespread, even in high-volume refractive centres. This is largely due to the significant financial costs involved in its implementation. Although costs are likely to reduce with competition and more entrants to the market, it is probable that the initial cost of the FLACS platform itself will be between US$400 000 and $500 000. Furthermore, a usage fee is likely to be $150 to $400 per eye and maintenance costs are estimated to be around $40–50 000 per year. If surgeons are confident in their own microsurgical skills and outcomes, it could be difficult to justify the additional expense, except perhaps in a very high-volume refractive cataract practice.
In a state-funded healthcare system, without the use of premium intraocular lenses, the use of FLACS will no doubt be questioned. The current NHS Tariff to perform cataract surgery is £704. The benefit of doing a capsulotomy using a £500 000 laser compared with a needle costing a few pence must correlate with the proportional benefit in outcome. At the present time, outside of toric and accommodative IOL use, this does not exist and consequently there is, so far, no reimbursement scheme from either private medical insurance or national health systems.
However, with time and marketing, it is likely that the public perception will change. As awareness of femtosecond technology increases, we will start to experience more and more patients asking about or demanding FLACS. This may necessitate a change in the state-funded healthcare system to allow top-up care, where patients are given the option of paying extra for the premium IOL and laser technology. A system of 'co-payments' such as this is already permitted in some European countries, but not currently in the United Kingdom. Another method of improving economic viability may be through 'bundled discounts', whereby companies reduce the cost of their laser machines in return for a supply contract for other surgical instruments and IOLs.
From a practical viewpoint, the implementation of FLACS in the NHS would require a complete system redesign of existing cataract surgery pathways. The consent process, often conducted by senior nurse practitioners in high-volume units, may need to be replaced, at least in the early stages, by a detailed discussion by the operating surgeon. It has been suggested that surgery should not be conducted on the same day as preoperative assessment. Operating theatre space would have to be created to fit the laser, with extra space required to allow transfer of either the patient or the phacoemulsification machine to permit the second stage of the operation. It is thought that there is a window of opportunity lasting 2–3 h after femtosecond capsulotomy, before leaking lens proteins elicit an anterior chamber inflammatory reaction. Therefore, to improve efficiency, two or three patients could be pretreated with the FLACS system before lens removal and IOL implantation in the operating theatre. One model has been proposed, whereby a single laser suite, operated by one surgeon, feeds into several operating theatres with other surgeons completing the manual parts of the procedure. A situation could result where cataract surgery is no longer performed in smaller hospitals or outreach theatres, with it instead becoming centralised using a 'carousel' model in larger units with access to femtosecond technology. If superior efficacy and safety profile can be demonstrated conclusively, it is conceivable that FLACS may eventually have a role in the management of complex cataracts within the public sector.
Economics and Financial Considerations
Despite its perceived benefits, FLACS is not yet widespread, even in high-volume refractive centres. This is largely due to the significant financial costs involved in its implementation. Although costs are likely to reduce with competition and more entrants to the market, it is probable that the initial cost of the FLACS platform itself will be between US$400 000 and $500 000. Furthermore, a usage fee is likely to be $150 to $400 per eye and maintenance costs are estimated to be around $40–50 000 per year. If surgeons are confident in their own microsurgical skills and outcomes, it could be difficult to justify the additional expense, except perhaps in a very high-volume refractive cataract practice.
In a state-funded healthcare system, without the use of premium intraocular lenses, the use of FLACS will no doubt be questioned. The current NHS Tariff to perform cataract surgery is £704. The benefit of doing a capsulotomy using a £500 000 laser compared with a needle costing a few pence must correlate with the proportional benefit in outcome. At the present time, outside of toric and accommodative IOL use, this does not exist and consequently there is, so far, no reimbursement scheme from either private medical insurance or national health systems.
However, with time and marketing, it is likely that the public perception will change. As awareness of femtosecond technology increases, we will start to experience more and more patients asking about or demanding FLACS. This may necessitate a change in the state-funded healthcare system to allow top-up care, where patients are given the option of paying extra for the premium IOL and laser technology. A system of 'co-payments' such as this is already permitted in some European countries, but not currently in the United Kingdom. Another method of improving economic viability may be through 'bundled discounts', whereby companies reduce the cost of their laser machines in return for a supply contract for other surgical instruments and IOLs.
From a practical viewpoint, the implementation of FLACS in the NHS would require a complete system redesign of existing cataract surgery pathways. The consent process, often conducted by senior nurse practitioners in high-volume units, may need to be replaced, at least in the early stages, by a detailed discussion by the operating surgeon. It has been suggested that surgery should not be conducted on the same day as preoperative assessment. Operating theatre space would have to be created to fit the laser, with extra space required to allow transfer of either the patient or the phacoemulsification machine to permit the second stage of the operation. It is thought that there is a window of opportunity lasting 2–3 h after femtosecond capsulotomy, before leaking lens proteins elicit an anterior chamber inflammatory reaction. Therefore, to improve efficiency, two or three patients could be pretreated with the FLACS system before lens removal and IOL implantation in the operating theatre. One model has been proposed, whereby a single laser suite, operated by one surgeon, feeds into several operating theatres with other surgeons completing the manual parts of the procedure. A situation could result where cataract surgery is no longer performed in smaller hospitals or outreach theatres, with it instead becoming centralised using a 'carousel' model in larger units with access to femtosecond technology. If superior efficacy and safety profile can be demonstrated conclusively, it is conceivable that FLACS may eventually have a role in the management of complex cataracts within the public sector.
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