A Top Laser and Cataract Surgeon Says "The Jury Is Still Out" on Laser Assisted Cataract Surgery

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San Diego Ophthalmologist Sanford G. Feldman M.D. dishes on the new, “bladeless” laser cataract surgery. The jury is still out as not all eye doctors are convinced laser is better than traditional cataract surgery – yet.

Cataract Surgery San Diego

Sanford Feldman M.D. at One to One LASIK in San Diego is a nationally recognized expert on eye health education and believes in taking the time to teach his patients about their eyes, One to One.

...the truth is very few surgeons are using it so far and the jury is still out on its benefits and risks.

Recently there have been ads about “bladeless” or “laser-assisted cataract surgery.” What is this all about? And, is it better than traditional cataract surgery? Here’s the scoop:

A cataract is a cloudy lens inside the eye that causes blurry vision. Contrary to popular belief, a cataract is not a film on the surface of the eye. When cataracts become bothersome, they can be removed with a low-risk, highly effective and essentially painless operation. For years, many people have assumed that cataracts are removed with a laser. But until very recently, cataract surgery did not involve lasers at all. Traditional cataract surgery is a painless, 20 to 30 minute operation that involves making a pencil-tip size incision in the cornea (the front window of the eye) with a microscopic blade, opening the thin skin that surrounds the cataract with a hand-held instrument, breaking the cataract into tiny fragments with ultrasound waves, vacuuming the fragments out through the same tiny opening, and inserting an artificial plastic lens called an intraocular lens implant. The implant is folded up like a taco so it can be inserted through the small incision. Once inside the eye, it unfolds to full size and remains there, replacing the focusing power that is lost when the natural lens is removed.    

In the last year, the FDA has approved (or partially approved) several companies’ version of a laser called a femtosecond laser designed to assist with various steps in cataract surgery. The trademarked brand names of these machines include “LenSx,” “LensAr” and “Catalys” and there are more on the way. The femtosecond laser has been in use for many years in LASIK laser vision correction surgery to make the LASIK corneal “flap” without a blade. But use of femtosecond lasers in cataract surgery is very new. Fewer than 100 machines are in use throughout the United States so far, and only small minorities of cataract surgeons are using them.

By reading some of the ads one might think cataract surgery itself has been replaced by just having a light beam quickly shined at the eye, causing the cataract to disappear magically. That is not at all the case. A fully approved femtosecond laser can be used for four specific steps in cataract surgery:

1) It can be used in place of a blade to make the primary incision through which the cataract fragments will be removed. That’s why laser-assisted cataract surgery is often referred to as “bladeless” cataract surgery in advertisements.

2) It can also be used to make extra incisions in the cornea designed to decrease astigmatism. Astigmatism means that the front of the eye is shaped more like a football than a basketball. This causes blurred vision that can be corrected with glasses or contacts. Decreasing astigmatism at the time of cataract surgery can mean less dependence upon glasses for best vision after surgery. The femtosecond laser is not the only way to reduce astigmatism in a cataract surgery patient. Astigmatism correcting incisions can also be made with a blade, but they are less precise than those made by laser. Astigmatism can be corrected with LASIK or PRK after cataract surgery, but this requires a second procedure. And, there are astigmatism correcting (or “toric”) intraocular lens implants. Advanced new lens implants that correct both distance and reading vision work best when there is no astigmatism. So, any method that can predictably and accurately reduce astigmatism at the time of cataract surgery can increase the number of patients who are candidates for these specialized or “premium” lens implants.

3) The femtosecond laser can also be used in place of a hand-held instrument to open the front skin of the cataract or “anterior capsule.” This step is called an “anterior capsulotomy.” The laser can make a more precisely round and accurately sized anterior capsulotomy than is generally possible when it is made by hand. Some doctors think that a more precise anterior capsulotomy can help keep an intraocular lens more perfectly positioned, and that this can result in better vision post-operatively. However, there have not yet been enough carefully controlled research studies to prove that this is true. The issue is still under study.

4) Finally, the femtosecond laser can be used to break the dense central “nucleus” of a cataract into fragments. The surgeon still has to insert the ultrasound instrument into the eye to remove the fragments, but less ultrasound energy is required when the femtosecond laser is used first. That can mean less swelling of the cornea from the ultrasound and quicker return of vision after surgery. Again, there are not enough research studies to prove that the laser-assisted cataract surgery allows quicker vision recovery than conventional surgery.    

With either the laser-assisted method or the traditional method, the intraocular lens implant still needs to be inserted with hand-held instruments. Laser-assisted cataract surgery usually takes a bit longer than conventional cataract surgery, because the patient must first be treated with the laser and then moved to the operating room for the remainder of the surgery. And, use of lasers doesn’t appear to improve recovery time. Most people who have cataract surgery by any modern method are on their feet the same day and back to normal vision and activities within just a couple more days. Finally, it should be no surprise that there is a premium to be paid for use of the femtosecond laser. Eye surgeons are not allowed by Medicare to charge more for using the femtosecond laser to remove a cataract. But they can and do charge for using the femtosecond laser to treat astigmatism at the time of cataract surgery. Charges vary from doctor to doctor but usually range from $500 to $1750 dollars per eye beyond what insurance will pay. And that does not include any additional out-of-pocket charges for patients choosing “bifocal” or astigmatism-correcting lens implants.

Laser-assisted cataract surgery is relatively new and is considered very safe. But, but as with all new technologies, the full range of potential complications is not yet known and the machines and surgical techniques are still being refined.

The important thing to know about laser-assisted cataract surgery is that one should not automatically assume that it is better just because a laser is involved. It’s an exciting advance. And, if one has astigmatism and would like to reduce the need for glasses to see best after cataract surgery, it may well be worth discussing laser-assisted cataract surgery with an eye surgeon. But if one is shy about being among the first to have a procedure with relatively new technology, doesn’t have astigmatism, or doesn’t mind wearing glasses to correct astigmatism after surgery, it may not be worth the extra cost. As remaining questions about both advantages and disadvantages of laser-assisted cataract surgery are answered, and as the technology is refined, it is likely that the use of lasers in cataract surgery will become much more widespread.

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Sanford G. Feldman M.D.
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