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Up Front | Jun 2002

The Integration of IntraLASIK

What implementing the femtosecond laser has meant for one practice.

My practice received the INTRALASE FS Laser (IntraLase Corporation, Irvine, CA) and implemented the IntraLASIK procedure in January of this year. I chose to add this technology to my practice because I recognized that microkeratome technology is not perfect—even with ideal operating conditions, highly experienced technicians, and a highly experienced surgeon, microkeratomes have a measurable failure rate. I feel that any failure rate above zero is unacceptable for an elective surgical procedure. Therefore, in order to limit the number of variables that can create an adverse result, I wanted to be able to offer the femtosecond laser to my patients. I feel that IntraLASIK is the next logical choice for performing safer and ultimately more accurate refractive procedures.

Approximately 90% of our LASIK cases are performed with IntraLASIK. Ideally, I feel there is very little indication for using the microkeratome to perform a refractive procedure. However, there are some situations in which the microkeratome is still preferable.

Rare Cases
In very rare circumstances, performing IntraLASIK can be a challenge. Patients with abnormally tight lid fissures can make it difficult for the surgeon to insert the vacuum ring, as it is currently available in only one diameter. There are also some medical conditions for which the microkeratome is more practical. One patient on whom we operated recently suffered from severe torticollis, which caused her head to turn uncontrollably to the right. Due to the docking mechanism and the longer time required for the flap creation with the INTRALASE FS Laser, the microkeratome was her only option.

Patient Preference
Another reason that we have not completely abandoned classic LASIK is that although we spend a great deal of time educating our patient base that IntraLASIK offers superior surgery, it is more expensive than traditional LASIK, and under current economic conditions it has been somewhat difficult to raise the price of surgery in our area. In addition, we have many referral patients who sometimes find it hard to believe that the new method of surgery is that much better when their friend or family member is doing so well despite having undergone surgery with a microkeratome. As a result, they resist our attempts to charge them an additional fee for a new procedure. The approach we have taken with this form of temporary resistance to IntraLASIK is to acknowledge that the microkeratome is the ?gold standard? for LASIK (and you cannot really apologize for using a microkeratome when 99.9% of all LASIK in the world is performed with this instrument), but to explain that IntraLASIK is the new ?platinum standard.?

A Benefit in Offering Both
The third reason why we have not fully converted to an all-IntraLASIK practice is because of competition. Although we are proud to offer patients the latest, safest LASIK technology, we do not want to alienate prospective patients who may prefer microkeratome technology to IntraLASIK. They may have heard negative, however inaccurate, information about the IntraLASIK procedure, such as the femtosecond laser's flap does not adhere as well, or the quality of the bed is not as good. Some patients may ask for traditional LASIK because of its lower cost or speedier surgical time, or some may simply feel that the femtosecond laser technology is too new compared to the tried-and-true microkeratome. Although we thoroughly counsel our patients about the inherent problems with microkeratomes, it is surprising that we still have patients who choose to undergo traditional LASIK. However, If patients feel strongly about undergoing LASIK with a microkeratome, we believe that we can provide the best possible surgical result in that arena as well. Offering both technologies provides educated patients with alternatives and is another way we differentiate ourselves from other practices.

We have found that not only is the INTRALASE FS Laser a safer device than the microkeratome, but it also offers superior predictability and better quality of vision, particularly for hyperopes, patients with high astigmatism, high myopes, or patients with mixed astigmatism. For these challenging cases, we have had much more predictable results with the INTRALASE FS Laser than with the microkeratome. Rather than bring a patient back for an enhancement, we prefer to treat him or her more effectively the first time. For example, a patient who is a +6.0 D hyperope with -6.0 D of astigmatism will most certainly require an enhancement if we use the microkeratome. The planar flap created by the IntraLASIK procedure significantly improves our outcomes for such a patient, and there is a very high probability of successfully treating him or her with one procedure. In addition, we often perform refractive surgery on patients who have large pupils, high corrections, and thin corneas. Although we may be able to cut a 100-µm flap with the microkeratome, we cannot be assured of predictably obtaining this flap thickness in 100% of these cases. Rather than risk ectasia, we insist that such patients undergo IntraLASIK instead of classic LASIK. Obviously, we try to present the patient with adequate information so they can make a rational, reasonable decision, but there may be compelling medical reasons that suggest he or she would be a better candidate for one procedure over the other.

Our patients appreciate that we are honest and open about the advantages and disadvantages of the IntraLASIK procedure. The only adverse events we have experienced with IntraLASIK is that it takes a little longer to perform than traditional LASIK, and there may be some redness in the eye for a short time after the surgery. Once patients recognize the procedure's safety factor and its potential for improved outcomes, they embrace it with enthusiasm.

The population in Vancouver, Washington, has been conditioned for several years by the LASIK discount centers in Canada into believing that LASIK is worth approximately $500 to $700 per eye, so for us to now charge $2,000 per eye is a huge paradigm shift. It will take a little time for our market to adjust, but these are temporary regional factors that will vary between centers, and we fully expect that IntraLASIK can demand a premium fee in the market.

I feel that the INTRALASE FS Laser is a truly remarkable medical advancement, and it has outperformed our high expectations. Although we acquired the system based upon its promise of providing a higher margin of surgical safety, we have been extremely impressed with its ability to deliver more accurate and more predictable refractive outcomes. Because it is a new technology, I believe that we will continue to discover even more areas in which it will enhance our ability to perform refractive surgery with a greater degree of precision than ever before. Although there is a higher cost associated with its use, as clinicians and patient advocates, we cannot compromise quality of care over financial cost. Based on our experience, I consider today's IntraLASIK technology truly futuristic in corneal refractive surgery.

Brian R. Will, MD, serves as Medical Director at Will Vision and Laser Centers in Vancouver, Washington. He has no financial interest in any technology mentioned herein. Dr. Will may be reached at (360) 885-1327; drwill@willvision.com
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