26 Incorporating the Femtosecond Laser in Daily Practice
Summary
Laser system placement in a clinic, surgery center, or hospital should maximize efficiency during operating days. The laser’s operation can be done in a two-surgeon approach or with an extra technician who seems to be a profitable investment for busy centers. Advertising the laser should focus on the likelihood of achieving a good visual acuity (up to 90% within 0.5 D of target) though the need to still wear glasses under some circumstances should be stressed. Careful patient selection is crucial to a successful surgical outcome in refractive cases as well as in therapeutic indications. Any optical opacity, for instance, may limit laser penetration, including scarring, arcus senilis, iron deposition, or verticillata. As with any technology, there is a learning curve, and patient safety should always come first.
Keywords: patient selection, marketing, cost, efficiency, economics
26.1 Introduction
26.1.1 Financial Efficiency: Determining Which Laser
Successful incorporation of any new technology into a practice requires effective surgical use as well as efficient financial and operational planning. As such, the cost of lease or purchase options for different lasers must be balanced against the surgical functions offered by the individual lasers when considered within the caseload and growth strategy of a given practice. Some offices or surgery centers will only want cataract or corneal functionality, while others will want the full range of capabilities described in previous chapters. For reference, the surgical capabilities of some of the most common broad-use femtosecond cataract and corneal lasers are displayed in ▶ Fig. 26.1. Given that lease and purchase agreements vary significantly, specific discussions are beyond the scope of this discussion. Because of the destructive nature of the laser upon optical components within a femtosecond system, no laser is identical to any other laser. For this reason, settings for a given laser may be inadequate for another, and may explain the variation in incomplete capsulotomy frequency in the literature. For a given spot separation, settings both too low and too high can cause incomplete cuts, since too low insufficiently cuts the tissue, while too high creates bubbles that prevent adjacent shots from cutting. Roll-on/roll-off lasers are now available and would seem to be an efficient system to maximize laser use and spread the costs. These lasers, which may feature changes in settings between surgery days or even a different laser in a busy metropolitan area, may not provide the same predictable surgical function, however.
26.1.2 Operational Efficiency: Laser Placement and Patient Flow
Laser system placement in a clinic, surgery center, or hospital should maximize efficiency during operating days. Most purely refractive clinics or centers already have years of experience with optimizing patient flow. This discussion will focus on operating room incorporation of the laser, whether for cataracts, transplants, or other operating room procedures.
Placement of the femtosecond laser system inside of an operating room presents both advantages and challenges. Generally, the advantages are surgical in nature, while the disadvantages lie in lost efficiency. Miosis due to prostaglandin release from femtosecond anterior capsulotomy during cataract surgery is well described, 1 and minimizing transportation delay between femtosecond and microscopic surgical steps may reduce the surgical difficulty from this miosis. For cases with small pupils or posterior synechiae, sufficient pupillary dilation may be surgically obtained, wounds stabilized, and the femtosecond laser may be used once visual access to the lens is restored. In such cases, maintaining a sterile room is clearly advantageous. For corneal transplantation with femtosecond laser cuts, donor tissue may be prepared in a sterile operating room (OR) while the patient is ready in the same room for the femtosecond recipient corneal preparation, such that a surgeon may avoid leaving the prepared donor tissue to perform the laser portion on another patient in a different room. Importantly, some laser designs lend themselves to easier OR laser use, depending on gantry design and whether the design features a permanent bed or accommodates a surgical stretcher. A careful review of the history of types of cases is important; will the laser reduce the efficacy of the center overall?
In many situations, better efficiency may be achieved with the laser out of an operating room. Patients may be moved, prepped, and draped at either the laser or in the OR without preventing concurrent use of the other space, allowing greater utilization of expensive OR time. Nonoperating room placement is typically dependent on available space. When possible, maintaining unidirectional patient flow in the same surgical stretcher through the whole preoperative to postoperative process is ideal. A pass-through laser bay can assist in bridging the benefits of non-OR efficiency and utilization with prompt and smooth transitions between phases (Thompson VM, personal communication, September 17, 2015; ▶ Fig. 26.2).
Fig. 26.2 In this model, which features a pass through laser bay, circular flow allows smooth, efficient transitions (arrows) between phases of care in a two-room surgical center to maximize surgeon efficiency.
Some have advocated a two-surgeon approach, in which one surgeon does the laser portion, and the other performs the rest of the surgery in the OR, 2 which harkens back to the classic Fyodorov assembly line microsurgical concept. 3 Patient rapport and intersurgeon communication would likely be addressed differently in this model, since new issues would be created. If the same surgeon does both, the laser portion can serve almost as a trial for the surgical portion and increase patient comfort with the surgeon; with two operators, there may be more confusion to who “actually” performed the patient’s procedure.
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