Laser cataract surgery – is it worth it?

Conventional cataract surgery has come a long way since the first records of cataract removal in 2000 BC. To get to know more about the history of cataract, please read my blog post: The history of cataract surgery.

Cataract surgery is one of the most successful operations performed in medicine today with excellent outcomes and a low risk of complications.

This has not stopped eye doctors looking for better ways to improve the steps of cataract surgery. The latest innovation that has been applied to cataract surgery is the use of femtosecond laser to improve certain surgical steps. This is known as femtosecond laser assisted cataract surgery. There are many types of laser used in ophthalmology and it can be confusing which lasers are used for which eye conditions – my article here explains the different types: So what do you think of this laser eye surgery, doc?

The femtosecond laser is mainly used in refractive laser eye surgery to correct people with long or short sightedness but recently its use has been extended to three specific steps of cataract surgery:

3 Steps in laser cataract surgery

In conventional cataract surgery, the surgeon uses a small blade to make a careful opening into the edge of the cornea (the clear tissue at the front of the eye) – this is usually made in a stepped fashion so that the wound acts like a valve and self seals without the need for stitches.

In laser cataract surgery, this wound is made automatically using laser pulses of very high energy to cut the cornea. The surgeon is still responsible for programming the computer so it knows where and how to make the cut but this step becomes more automated as a result.

Does this more automated step mean that laser is better than the hand of a surgeon? The general consensus is that laser is more accurate than a surgeon’s hand.

Does this mean better results? This is still up for debate and we are conducting studies to answer this question more thoroughly.

Some patients have corneal curvature irregularities known as astigmatism. If these patients require cataract surgery it is possible to reduce these irregularities at the time of surgery by making extra cuts into the cornea. This relaxes its curvature – this is known as astigmatic keratotomy and is done with a blade by your surgeon. This may help improve the chance of better vision after your cataract surgery and less likelihood to need glasses for your chosen distance (if choosing a monofocal lens) or being glasses free (if choosing a multifocal).

Femtosecond laser can also be used to correct the astigmatism by creating more accurate and precise cuts into the cornea.

The evidence suggests that femtosecond laser is better than a surgeon’s hand in correcting astigmatism in patients that have it.

The cataract lies within a clear bag called the capsular bag. In conventional cataract surgery, the surgeon makes a continuous circular opening (5 to 6mm in diameter) into the front part of the capsular bag. This is required to gain access to the cataract in order to remove it. The remainder of the bag is left intact in the eye so it can hold the new intra-ocular lens that the surgeon implants.

In conventional cataract surgery, the surgeon opens the front of the bag manually using a fine needle and forceps. The aim is get to a near perfect circular opening in the front of the bag to ensure that your new intra-ocular lens sits centred within your eye. If the capsular bag is torn, then the new intra-ocular lens may well not sit in the centre of your eye and your vision may not as good as we had hoped for.

In laser cataract surgery, the femtosecond laser automatically makes the circular opening in the front of the capsular bag by producing high pulses of energy to cut the bag. The idea is that the laser can do this more accurately than the human hand.

The evidence suggests that the laser is indeed more accurate than the human hand as expected. However this step of cataract surgery is often deemed relatively straightforward by most experienced surgeons and some think that automating it with a laser may not improve vision results.

It seems that the actual characteristics of each person’s bag such as its flexibility and the way it is held in the eye has more to do with the risk of abnormal centering than the way we open the front of the bag.

Some surgeons believe that a more precise circular opening with the femtosecond laser is important in patients who are receiving multifocal orpremium intra-ocular lenses. We are still awaiting study data to see if this is the case.

In conventional cataract surgery, the surgeon uses a process calledphacoemulsification to break up the cataract into small pieces and remove it from the eye. This machine has a probe that vibrates at very high frequencies that fragments and cuts into the cataract. The same probe sucks up the tiny cut pieces. This invention was a big leap forward in the way we performed cataract surgery (see my history of cataract surgery blog for more details) because eye surgeons were able to make much smaller cuts into the eye as the end of the phacoemulsification probe was narrow.

The main downside of phacoemulsification is the production of heat and this has the potential to damage the inside cell lining of the cornea – if too much heat is produced then the cornea could become permanently cloudy and vision can be very hazy. Some also believe that this increased heat could lead to an increase in other complications such as retinal detachment. Thankfully modern phacoemulsification probes are very efficient nowadays and don’t produce heat damage in this way very often.

The femtosecond laser has now been used to cut the cataract into pieces(phacofragmentation) and it is thought that it produces much less heat damagethan the phacoemulsification probe. This is yet to be proven and further studies may answer this theory.

It must be mentioned that although femtosecond laser breaks the cataract into pieces, the surgeon still has to rely on the phacoemulsification probe to break it up further and remove the cataract pieces completely.

Femtosecond laser has not replaced phacoemulsification completely in the cataract removal step of cataract surgery.

We also are awaiting studies to show whether femtosecond laser is associated with less accidental breakage to the capsular bag than conventional phacoemulsification. Breaking the capsular bag has been shown to be associated with worse vision results and therefore this question is an important one that needs answering.

Cases for and against Laser Cataract Surgery

The only way I can tell you whether laser cataract surgery is worth it for you is to assess your specific needs and perform a full examination of your eyes at my practice in London.

So we go back to the question of ‘is laser cataract surgery worth it?’

At this point time there is a significant additional cost to the patient in using femtosecond laser for cataract surgery – this can be up to an additional £1200 on top of your price of routine private cataract surgery.

Why is this so expensive? Unfortunately the cost of buying the laser is fairly expensive and that cost often gets passed on to the patient.

At this point in time, I would say that conventional private cataract surgery is excellent in the hands of an experienced eye surgeon and that using the femtosecond laser in the three steps of cataract surgery described above may not warrant that extra cost yet in every patient.

Once we have the results of the studies that fully evaluate the benefits of femtosecond laser assisted cataract surgery, we may be in a position to say whether is definitely better and which type of patient will especially benefit.

Remember you are unique and each patient’s requirements are different.


Is laser cataract surgery worth it?

Not in everyone yet.

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