Smart Equipment Makes a Difference

A new and advanced pattern scan laser photocoagulator changes the way the day goes for patients, physicians and practices.

Dr. Singerman: All of the panel members currently use a PASCAL Pattern Scan Laser Photocoagulator (OptiMedica, Santa Clara, Calif.). The PASCAL photocoagulator is designed to treat retinal diseases using a single spot or a predetermined pattern array of up to 56 spots. It utilizes a proprietary semiautomated pattern generation method that employs short 532-nm laser pulses. The pulses are delivered in a rapid predetermined sequence with the goals of improving precision, safety and patient comfort and reducing treatment time compared with single-spot photocoagulation.

The PASCAL can deliver patterns that include single spot, square arrays, octants, quadrants, macular grid and arcs. As many as 25 spots can be delivered in 0.5 seconds. What impact has this instrument had on patient flow and efficiency in your practices?

Dr. Lehr: When I first read the article by Mark S. Blumenkranz, MD,¹ I was impressed that this type of laser photocoagulation could be done. This kind of technology had been discussed for years but only just materialized with the PASCAL.

It was clear to me on the first day when we brought the demo unit into the practice what a big step forward it is. It gives us the ability to perform panretinal photocoagulation (PRP) as well as other treatments in a timely fashion. We do not have to worry about bringing patients back several times. PASCAL has taken away the burden of doing PRP.

Dr. Gonzales: We started using the PASCAL photocoagulator about a year and a half ago and have been very impressed with how it has increased our efficiency. A PRP session takes me about one-fourth the time it used to with a traditional single-spot delivery system. This means that patients who need PRP can be treated during my clinic hours on the same day as the exam. I do not have to bring them back on another day or perform my laser treatments at the end of the clinic day.

Dr. Singerman: I agree. I am sure that before the PASCAL laser, we all did PRP on the same day when it was needed, but it really made the day tougher. With the PASCAL laser, the procedures are fast. For me, too, they take about a quarter of the time they used to, depending on the case. If a fair amount of hemorrhage is present, it may not be quite that fast. But if you have a clear view, PRP for neovascularization that has never been treated often can be done in an eighth of the time we are accustomed to needing.

OptiMedica's PASCAL Pattern Scan Laser Photocoagulator can deliver as many as 25 spots in just 0.5 seconds.

You can put in as many spots as you want in a very short time. You are no longer limited by time or the patient's comfort level. Instead, the determining factor is your comfort level at putting in more than 1500 spots or whatever number you choose. This instrument is the antithesis of the xenon and argon lasers that we used in the original Diabetic Retinopathy Study. It is a short-duration laser. You can apply many more spots with no problems compared with standard lasers, and you can do it faster.

In addition, the pattern concept is much better. For example, you can choose tight or wide spacing between spots, and the spacing is perfect. None of us could do one spot at a time with this kind of precision. Not having confluent burns should allow preservation of more visual field in the long run. In my experience, the PASCAL laser not only provides faster care but also better care. It also allows safer and more comfortable application of treatment.

Dr. Gonzales: There are two other features of the PASCAL laser that may enhance safety. First, as the physician varies the power and duration of the laser spots, the PASCAL calculates the fluence and displays the number on the screen. We did not have that advantage with previous systems. I should note, however, that the fluence calculation does not take the lens magnification into account, so the fluence that is displayed needs to be divided by the square of the spot size magnification factor. For example, when using a Mainster 165 contact lens, which has a spot size magnification factor of two, the fluence calculation needs to be divided by four. Second, because the duration of the procedure is shortened, patients are less likely to become fatigued and move. Therefore, we are less likely to have complications related to excessive patient movement.

PROVIDING BETTER CARE

Dr. Brown: After we tested the PASCAL in our practice — we have several physicians — we had to reach a consensus on whether to purchase one. It costs more than other photocoagulators, but we agreed to acquire the PASCAL, and it is one of the best decisions we have ever made. It is simply better care.

Take diabetic patients, for example. They are sick people and many of them are anticoagulated. The PASCAL basically allowed us to eliminate retrobulbar blocks and their secondary complications. With retrobulbar injection out of the risk-benefit equation, I am more likely to add PRP when I would like to. That eliminates vitrectomies in many cases and leads to better visual outcomes.

[The PASCAL] is a short-duration laser. You can apply many more spots with no problems compared with standard lasers, and you can do it faster. — Lawrence J. Singerman, MD

I do not want to be misleading: The PASCAL is not pain-free. However, I can tell my patients that it still hurts, but by the time they are ready to quit, I have finished the PRP pattern.

Dr. Lehr: I would add that with some patients, we are concerned about whether they will come back for additional laser sessions. Using the PASCAL, I feel comfortable performing a complete PRP, and I feel the patient has received good care in case they do not return as recommended.

Dr. Singerman: Yes, and because the patients are more comfortable, compliance is better. They will come back for another treatment session because they did not have a horrendous experience. Patients I have treated with scatter laser in past years notice the improved comfort with the PASCAL, which is encouraging.

Dr. Brown: This laser has helped us with efficiency in our satellite offices as well as our main office. It clears the PRP procedures out of the satellites. I tell patients they can drive to the main office and have their procedure with a better laser and without the 2-inch needle behind the eye. Ninety-five percent of them say "I'm there."

COST VS. BENEFIT

Dr. Singerman: Like Dr. Brown, we have multiple doctors in our practice who must agree on capital purchases. For the majority of our physicians, the cost of the PASCAL was not an issue. During our meetings on the subject, they cited the efficiency of the treatments and how much the time saved was worth it to them.

Dr. Lehr: In my practice, the only physicians are my partner and I. We calculated that we paid for the PASCAL photocoagulator just over 16 months after purchasing it. The efficiencies it fosters allow us to open up at least seven to 10 new clinic spots per week.

Dr. Singerman: It is nice to hear that the instrument paid for itself quickly in a relatively small practice. In our large practice — we have nine offices — we have had a strong return on investment. The PASCAL is in our main office, which we use six full days each week.

FEATURES BASED ON DOCTOR INPUT

Dr. Brown: We have talked about how quickly we can perform treatments with the PASCAL photocoagulator. I love how fast it is, but overall it is just a better laser — period. When I am doing a single-spot focal treatment close to the fovea, for example, the focus is better and the control is better. We bought the laser because of its pattern delivery abilities, but it is the best option in many other ways, as well.

Dr. Singerman: I like the micromanipulator. The control is very good.

Dr. Brown: The ability to adjust the power up or down on the unit while performing PRP gives us much more control over the procedure.

Dr. Lehr: It is wonderful to be able to make the adjustment from right there as you are moving more anteriorly and decreasing the power.

Furthermore, we have had zero patient phone calls regarding side effects or problems or complaints after PASCAL laser treatments. This has reduced the treatment burden from our technicians' point of view.

Dr. Brown: The ambient light underneath the unit, which helps me find the foot pedal, is one of many indications that retinal surgeons had a great deal of input into the design of the PASCAL.

Dr. Singerman: Input from several physicians experienced in laser was collected and used. The result is that the final product includes many features, in addition to the pattern-spot delivery, that represent significant advances in technology and ease of use.

USING ALL AVAILABLE TOOLS

Dr. Gonzales: We are practicing in an exciting time, being able to give patients better prognostic information and produce better outcomes. Although progress does present new challenges, new technologies, such as the PASCAL photocoagulator and electronic medical records, are beneficial in managing the challenges.

We have had zero patient phone calls regarding side effects or problems or complaints after PASCAL laser treatments. This has reduced the treatment burden from our technicians' point of view. — John T. Lehr, MD

Dr. Singerman: Yes, we now have technologies that are major steps forward in efficiency and patient flow. However, we will have to continue to improve in these areas. As the population continues to age and the incidence of diabetes and macular degeneration increases, the significance of managing the treatment burden will be all the more important. The challenge will stay with us. RP