Cataract Surgery Using Laser –

1. Clear Corneal Incision

In order to get to the cataract a surgeon needs to create an incision (cut) through the cornea. This is generally done with a very small, sharp metal or gem blade. These incisions are often self-sealing. The Femto laser can also make incisions in the cornea. However, there does not appear to be any real advantage to making these incisions with a laser. Indeed, many surgeons feel that use of a metal or gem blade allows them to better position the incision.

2. Creation of Capsulotomy

Creating an opening in the bag that holds the lens inside the eye is called “capsulorrhexis” (or “capsulotomy”). It is also one of the more technically difficult steps in cataract surgery. Many surgeons would appreciate having this step automated.

In addition, one of the major challenges in modern cataract surgery is “hitting the refractive target.” In other words, improving the surgeon’s ability to choose the correct IOL. In theory, a perfectly round, centered and sized capsulorrhexis could decrease some of the variability that currently limits a surgeon’s ability to “hit the target.” Although many ads have touted this as a benefit of Femto Laser-Assisted Cataract Surgery, such improved accuracy has yet to be proven.

3. Softening of Cataract

The energy used to emulsify the cataract with ultrasound can damage the cornea. Therefore, if the cataract could be made softer by cutting it into pieces with a laser prior to ultrasound then (at least in theory) there may be less damage to the eye during cataract surgery.

Alas, laser energy is also absorbed by the cornea. The cornea doesn’t seem to care whether it’s laser energy or ultrasound energy – it doesn’t like either one. So to state that laser cataract surgery results in less energy in the eye is a bit like telling someone they will save money if they pay for something in Euros instead of dollars. If the price of something is the same, does it matter what currency is used?

4. Correction of Astigmatism

Astigmatism is one of the reasons people need to use spectacles to see well. If the cornea is shaped more like a football than a basketball then astigmatism is present. The Femto laser can be used to place “relaxing incisions” in the cornea to address astigmatism at the time of cataract surgery. In theory these would be more predictable than incisions made with a metal or diamond blade. In practice, however, this has not been demonstrated.

Indeed, there are far more reliable and accurate methods of addressing astigmatism during or after cataract surgery. One such method involves placing an astigmatism-correcting intraocular lens (IOL) in the eye at the time of cataract surgery. The other is use of laser corneal refractive surgery (such as LASIK). Both of these proven methods of correcting astigmatism can be done without the use of a Femto laser.

It’s not. “But,” you respond, “I saw the ad and the brochure my doctor gave me said it would make the cataract surgery more precise.” Ah, you’ve been caught by a classic marketing ploy: confusing “precision” with “better result”. That’s what the marketers wanted you to think. However, there’s simply no compelling evidence to suggest that more precise creation of a capsular opening results in better final vision. Indeed, recent evidence suggests that those who have laser-assisted cataract surgery may be less likely to have improved vision than had they simply chosen cataract surgery without the use of a laser (more on that below).

Indeed there are. Bet the ad and brochure didn’t mention the following risks which are more likely to occur with laser-assisted cataract surgery than without:

1. Elevation of IOP and Pupil Constriction

The Femto laser must be “docked” onto the eye for proper alignment. This docking increases the intraocular pressure (IOP) inside the eye. For those with glaucoma this could potentially result in permanent loss of vision. Additionally, the docking and/or Femto laser procedure can cause the pupil to constricts^[1] making the surgery more challenging for the surgeon (and potentially increasing the risk of complications during the ultrasound portion of the surgery).

3. Retained Lens Material

The entire point of cataract surgery is to remove the damaged natural lens and replace it with a synthetic clear lens. The Femto laser can break up the lens making it easier to remove from the eye. Occasionally, however, some of these lens fragments can get lost in the eye only to be discovered during a post-operative exam in the office. If that happens then another surgery is generally recommended to remove the remaining lens fragment.

4. Corneal Swelling

One of the touted features of Femto laser-assisted cataract surgery (FLACS) is “softening of the lens.” The theory is that by using a laser to carve up the lens less ultrasound energy will be necessary in order to remove the lens. Less ultrasound use should be less damaging to the cornea resulting in less corneal swelling (edema). A very large European study (the “FLACS ESCRS Study”), however, demonstrated that those patients undergoing FLACS were five times more likely to experience corneal swelling than those who had cataract surgery without use of the laser! Why is this important? Because corneal swelling doesn’t always go away and can result in reduced quality of vision.

Speaking of reduced quality of vision…

5. Decreased Vision

As already mentioned, many of the ads and brochures describe laser-assisted cataract surgery as more “precise”. This term is intended to suggest that surgery performed with a laser will result in better quality vision. To date, no independent study (not funded by a company that makes or sells Femto lasers) has shown that use of Femto laser-assisted cataract surgery (FLACS) results in better final vision than cataract surgery without the use of the laser.

If there’s no objective evidence that Femto laser-assisted cataract surgery (FLACS) results in better final vision, then why use this technology? Fair question. But, reality may be even worse than that. The same European study that showed a higher rate of corneal swelling among FLACS patients  (the “FLACS ESCRS Study”) also noted that almost three times as many patients who had FLACS had worse vision after surgery than those who underwent cataract surgery without the use of the laser!

A commonly accepted rule-of-thumb among surgeons is that additional risk must be balanced by additional benefit to the patient. But, what benefit does the patient get for the potentially high price of added risk? Seemingly nothing other than a lot of hyperbole, vacuous promises of “greater precision”, and disingenuous suggestions that Femto Laser-Assisted Cataract Surgery is necessary in order to get the full benefit of “premium” IOLs.

Because of this combination of added risk without clear benefit to the patient, more than a few eye surgeons (myself included) now believe that charging patients for laser-assisted cataract surgery is not only unjustified, but potentially unethical. Medicine needs new technologies, and the benefit may not always be apparent early on in the adoption phase. That’s generally accepted in medical circles. Forcing patients to pay substantial amounts of money for unproven technology, on the other hand…

Laser-assisted cataract surgery costs hundreds to thousands of dollars more than cataract surgery done without a laser. Given the lack of proven benefit, what are your really getting for this extra fee?

First, why don’t we look at what Medicare (the largest payer of cataract surgery) says about this (you don’t really have to read this as it’s boring and I’m going to summarize it below). I’ve added emphasis to the key parts:

What?!

Translation: If you are a Medicare beneficiary you cannot legally be charged an extra fee for laser cataract surgery unless you have astigmatism or are opting for a “premium” or “refractive” intraocular lens (IOL) such as a multifocal IOL or “pseudoaccommodating” IOL (such as the Crystalens). You see, the Femto laser falls under Medicare’s “Golden Scapel” rule. It doesn’t matter whether a surgeon uses a metal, diamond, gold, or laser to perform surgery – unless something other than standard cataract surgery is done the surgeon or surgery center cannot charge Medicare patients an additional fee.

Correction of astigmatism or placement of “premium IOLs”, however, is considered refractive surgery. So long as refractive surgery is also being performed during cataract surgery then Medicare allows an extra fee to be charged to the patient.

“But,” you ask, “is the laser required for placement of a “premium” IOL or correction of astigmatism?”

The answer may surprise you: 

“No.”

So, why would anyone choose to pay more and undergo additional risk just to have their cataract surgery assisted by a laser? There must be scientific studies to prove that it is a safer and more reliable method of removing a cataract, right?

Wrong! (scroll up to “Is Laser-Assisted Cataract Surgery Better than Surgery Done without a Laser?”)

Millions of dollars have been spent by the manufacturers of Femto lasers to convince both doctors and their patients that laser-assisted cataract surgery is superior to cataract surgery performed without a laser. The industry has tried everything from intimate dinners at expensive restaurants to rock concert like presentations with laser light shows and loud music (I’m not kidding) to sway the views of eye doctors. Many have been impressed enough by these presentations to spend up to a half million dollars to purchase one of these Femto laser units. Yes, that’s up to $500,000 just to purchase the laser. On top of that the laser companies charge another $300-800 each time the laser is used on a patient.

But let’s say you’ve got a few thousand extra dollars burning a hole in your pocket. Should you go ahead and have laser-assisted cataract surgery just for braggin’ rights? I suppose you could. After all, spending hundreds to thousands of dollars to have Femto laser-assisted cataract surgery (which takes longer to perform than cataract surgery without laser use and has no convincing evidence that the final vision will be any better) is a bold statement that “I have money to burn”

But for my money and knowing my patients (who generally think taking unnecessary risk or throwing money away should be avoided, not bragged about), I think there’s more benefit and bragging rights to be had by spending those funds on a vibrant new 70” 4K flat screen TV like this one:

With your post-cataract surgery crystal-clear vision (which may be more likely without the use of the laser) you will now be able to enjoy the subtle beauty of this high-definition display as well as have something substantial to brag about.