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7 more than he did with the natural lens, you may end up with a frus- trated patient. Many 47-year-old cataract patients are not using their bifocals at computer intermediate distance, but once they have a traditional monofocal implant, they won't have the same intermediate vision they did preoperatively. They like knowing this ahead of time so they can make an informed decision. As you can see, I have not even mentioned thus far some of the other technologies that I use in refractive cataract surgery. This is because I believe patients want to hear about their vision options first rather than have to decide in an à la carte fashion what technologies I am going to use to get them there. But once I have figured out what vision they want to achieve, we go into the technology we use to achieve their goals. Because the femtosecond laser precision (incisions, capsulotomy, nuclear division/softening, and astigmatic keratotomy) has become so core to our refractive cataract program, we call it refractive laser- assisted cataract surgery (ReLACS). In addition to the femtosecond laser, we use intraoperative aberrometry for helping us achieve the most accuracy in our implant power selec- tion. We then let the patient heal for 3 months. If his or her vision is not ideal 3 months postoperatively, we then use the laser to perform an enhancement via PRK or LASIK. I emphasize to patients that cataract surgery, for the most excel- lent visual outcome, is often a two- step process with either traditional or advanced technology lenses. If they choose a traditional approach and implant, we perform the surgery, and then a month later the second step to fine tune their vision to its very best is prescribing quality glasses. If they choose an advanced technology surgery and implant, we perform the surgery, and then use a laser PRK or LASIK as the second step to fine tune the result to its best. In our practice, it is the doctor who explains how advanced tech- nology requires an investment by patients above and beyond what their insurance reimburses for therapeutic cataract surgery. Even though our surgical counselors cover the details, we find it is helpful for the doctor to begin the financial counseling about the cost of the patient's choice. Often, patients feel the investment is even more worth it when they learn that the advanced technology implants' reading and intermediate vision does not deteriorate over the years like their natural lens did. This is an important point to explain. As long as their eye health stays good, they will not experience gradual deterio- ration, so they are investing in a life- time of vision. When I go into a refractive cataract surgery case, I am glad that I'm using a laser. It is more precise, and I can reproducibly create better incisions, better capsulotomies, and better nuclear division so less pha- coemulsification energy is required. I am also glad that I have intraopera- tive aberrometry to help me with implant power selection so I can hit a home run on achieving their uncorrected vision goals. If I don't hit that absolute goal, I get close enough that they do not need temporary glasses while waiting 3 months for the refractive enhance- ment. Traditional cataract surgeons can start out in a smart way as they enter this premium arena but with time and growth in their advanced implant cases I predict they will become like I have—dependent on the femtosecond laser and the intraoperative aberrometer in my refractive cataract practice. Dr. Thompson is in private practice in Sioux Falls, S.D. He can be contacted at vance.thompson@vancethompsonvision.com. continued from page 2 continued from page 4 First, he said they should under- stand and believe in the technology. "If you don't have conviction, patients will sense this. Give a firm, consistent recommendation to patients, and visit a practice with proven success with LACS," he said. He recommended learning from how others invented their processes to give you a good idea about how to create your processes. Second, he recommended designing a practice around the fem- tosecond laser as much as possible. "Don't make it look like an after- thought. Engineer around foot- prints, flow, efficiency, and engage your staff in the process. If your staff hates your laser or its flow, their day is not made easier. A more difficult day for staff translates into a more difficult day for the patient," he said. Third, never assume a patient won't be interested in LACS. "Astig- matism management means better vision without glasses," he said. Dr. Rivera tells his patients that LACS makes the procedure easier on them, as well as the surgeon. Fourth, treat every patient until they reach not just "20/happy," but "20/ecstatic." Dr. Rivera has a preop discussion on patient expectations and speaks to the strengths of the technology. "However, always speak to weaknesses of the technologies as well," he said. Finally, take a serious look at the personality of your practice. "Do not be afraid to modify it when needed. LACS represents a premium mindset, and a premium mindset demands a premium experience. It's important to remember that it is not just cataract surgery anymore," he said. "LACS is not a fad. Overall it minimizes case-to-case variability, minimizes trauma to adjacent non- target tissue, and continually makes tough cases easier, and complicated cases more routine," Dr. Rivera noted. Minimizing phaco energy makes the procedure no longer "femtophaco" but "femtoemulsifica- tion" according to Dr. Rivera. "LACS represents the greatest innovation in cataract surgery since the advent of phacoemulsification. Femtoemulsifi- cation is here to stay and is not about practice revenue; it is about obtaining the best patient out- comes," he concluded. Dr Rivera's top 5 pearls for LACS integration 1. Understand and believe in the technology. 2. Design your practice around the femtolaser as much as possible. 3. Never assume a patient won't be interested in LACS. 4. Treat patients until they reach not just "20/happy," but "20/ecstatic." 5. Take a serious look at the personality of your practice and don't be afraid to modify it when needed. Refractive cataract surgery

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