With several platforms approved for use in international markets and one available in the US, wavefront-guided ablation is quickly becoming a standard fixture in many refractive practices. Cataract & Refractive Surgery Today asked a number of the world's top refractive specialists to discuss how the technology's arrival has impacted their markets and practices, and also to share some of their early experiences with issues such as patient candidacy and premium pricing. Louis Probst, MD, of Ann Arbor, Michigan; Michael Lawless, MD, of Chatswood, Australia; Sheraz Daya, MD, of London; John Doane, MD, of Kansas City, Missouri; Gordon Balazsi, MD, of Montreal; Howard Gimbel, MD, of Calgary, Canada, and Lucio Buratto, MD, of Milan, Italy, provided insights derived from being among the first ophthalmologists in the world to offer their patients wavefront-guided ablation.
Pricing For customized ablation
In his 18 months of performing customized ablations using the Zyoptix platform (Bausch & Lomb Surgical, San Dimas, CA), Dr. Probst has determined that his practice can charge a premium for the advanced technology. ?We currently charge $2,200 USD for custom and $1,700 USD for standard LASIK,? he states. ?Once the advantages of custom have been explained, this premium price is acceptable to patients. We originally began at $2,995 USD, but found that this was too high.?
Dr. Daya comments that there is a great deal of additional time needed to acquire wavefront images, evaluate data, and decide on candidacy, all tasks he believes are best performed by the operating surgeon. Consequently, he feels that the pricing for wavefront-guided ablations should be approximately £2,000 ($3,244 USD) per eye. Dr. Balazsi also acknowledged the increased time requirements for data evaluation and patient consultations. He believes that surgeons should charge at least $2,000 USD for custom procedures, adding that wavefront measurement is a lengthy procedure requiring the work of a skilled technician.
Dr. Buratto charges the same fee for standard and customized ablations, because he values the way this pricing simplifies working with his patients. He is, however, planning to increase his price for every laser procedure by 15%. Dr. Buratto also commented on the importance of discussing with his patients the intricacies of the technology and the investments required, both in terms of equipment and surgeon/staff training.
Patient Candidacy
The issue of patient candidacy varies between laser platforms, as well as among geographic locations. When asked which patients would potentially benefit from wavefront-guided ablation, Dr. Doane commented that, ?conceivably, anyone who has an asymmetric topography or wavefront could benefit, but, if the patient's topography and/or wavefront are symmetric across the major meridian, in theory, there would be little to no benefit.? Dr. Doane estimates that 50% to 70% of patients' eyes may benefit from an asymmetrical ablation. ?At present,? he added, ?performing a custom or asymmetric ablation for a starting refractive error above -6.00 D to -8.00 D may have only a limited benefit over a conventional ablation. On the flip side, custom treatment may benefit patients with higher refractive errors for enhancement surgeries if they are not satisfied with the initial treatment results.?
The data presented by the US investigators for Zyoptix on the treatment of myopia convinced Dr. Balazsi that all myopic patients benefit from wavefront correction. When asked what percentage of his patients would be candidates for wavefront-guided procedures, Dr. Balazsi stated, “Because we cannot yet treat hyperopia or mixed astigmatism with Zyoptix, I estimate that more than 80% of our patients are presently candidates.”
Between 20% and 30% of Dr. Probst's cases involve customized ablation, but he expects this proportion to increase by approximately 10% every 6 months as the results continue to improve and customization becomes the industry standard. He acknowledges that indications for customized LASIK are in a state of evolution, but his current recommendations are to treat eyes with preoperative higher-order RMS values of greater than 0.4 µm, greater than 6.00 D of myopia or 2.00 D of astigmatism, pupils larger than 7 mm, or a thinnest central pachymetry of less than 540 µm. The last four indications, he states, are used primarily “to take advantage of the tissue-sparing aspects of Zyoptix while still using the large blend zone for larger pupils.”
According to Dr. Daya, the best candidates are low myopes (up to -5.00 D) with large pupils who report night vision problems and have significant higher-order aberrations to account for their symptoms. ?In my experience, these are the patients who obtain good outcomes and are ecstatic with their vision,? he states.
Dr. Gimbel reports that he has evaluated and treated 12 previously untreated eyes with mixed myopic astigmatism using the NAVEX platform (Nidek, Inc., Fremont, CA). Each eye's visual symptoms resolved; no patient lost two or more lines of BCVA; but the postoperative RMS of higher-order aberrations did not always completely resolve or change in a predictable fashion. Based on these results, Dr. Gimbel feels that multipoint customized ablation is a safe and effective treatment for correcting mixed myopic astigmatism and for resolving visual symptoms in select refractive surgery candidates. He notes that small amounts of higher-order aberrations are not always reflected in a patient's subjective assessment of vision quality.
International Market impact
Dr. Buratto states that, ?so far, the custom experience in Europe has been one of getting started. There have been some frustrations, because we have not been able to secure the percentage of custom treatments we would like. As with any new technology, we are now taking the steps necessary to improve the use of wavefront data and increase the number of patients we can treat with this exciting new technology.?
Wavefront-guided ablations have been available in Australia for more than 1 year, with three platforms—LADARVision (Alcon Laboratories, Inc., Fort Worth, TX), Allegretto (Wavelight Laser Technologie AG, Erlangen, Germany), and Zyoptix—currently approved. Dr. Lawless has been using the Alcon platform, said the following regarding his recent experience: “I treated the first patients with wavefront-based LADARWave algorithms in January 2003. We are confident that with this combination of high-speed tracking and response, small-beam spot scanning, and the registration of the LADARWave alignment to the treatment using the LADARVision system, as well as the FDA data, that we now use the system routinely for any patients who fit the FDA criteria.”
Plight of the Noncustom practice
So will those practices that do not offer wavefront-guided LASIK be left behind? Dr. Daya believes that the answer to this question varies depending on the type of LASIK practice: ?A nuts-and-bolts, midrange practice will still attract the nondiscerning, price-conscious consumer. For the high-end practice that wishes to maintain its position in the market, however, custom ablation availability, whether or not it is used, is necessary.?
Dr. Buratto's response to this question was emphatic: “In both the short and long term, the answer is ‘Yes!' Patients are and will be increasingly aware of the benefits in terms of quality of vision, and those practices that will not offer custom procedures will probably experience a progressive drop in their procedural volume.”
Dr. Lawless agrees that such practices will likely be left behind. He believes that it will take approximately 2 years for the benefits of wavefront-based treatments to become apparent, although patients with larger higher-order aberration profiles preoperatively will report the technology's benefits earlier. He stated that ?the subtle benefits in night vision and improved contrast sensitivity will take some time to prove with clinical diagnostic tests, as well as to become symptomatically apparent to treated patients. My view is that, with the right platform, wavefront-based treatments will be the standard of care and will need to be marketed and priced accordingly.?
Because not every patient desires or requires wavefront-guided LASIK, and conventional treatment results for low myopes with low astigmatism (a category that constitutes the majority of refractive patients) have been excellent, Dr. Probst believes practices offering only standard LASIK will not be left behind—not yet, that is. “Therefore,” he states, “LASIK surgeons do not need to purchase a wavefront system right now, but they will need one within the next year as the indications become clear and competitors start to advertise custom LASIK.”
