On nearly every cataract evaluation we perform we get questions about whether or not cataract surgery is laser surgery. The short answer is “no.” However, we do perform laser assisted cataract surgery in which a few of the steps are performed by a femtosecond laser and other steps are performed manually. The truth is that the majority of all cataract surgery is performed with a device call a phacoemulsification handpiece through a very small incision. At the conclusion of the procedure a very small lens is folded and implanted in the eye. The type of lens implanted, and the accuracy of measurements taken to choose that lens, likely plays a much larger role in your final visual outcome than whether or not laser assisted cataract surgery was performed. The following article goes into much greater detail on laser assisted cataract surgery and can hopefully help you understand more about the situations in which laser assisted cataract surgery may be a better option from the traditional surgery and also situations where it may not.
The above video shows how the laser works and illustrates many of the concepts discussed in this article.
Which is better laser cataract surgery or traditional?
Traditional or manual cataract surgery can be nearly identical to laser cataract surgery in many situations but in certain situations the femtosecond laser can provide a distinct advantage. The type of femtosecond laser and whether or not it integrates with other technology used in the office also plays a role in how helpful the technology can be. In traditional small incision cataract surgery, the surgeon makes the incisions with a metal or diamond blade. Some practices will make the incisions with the laser however, Dr. Swanic finds that manual incisions made with a diamond blade seal better than incisions made with the laser, so he actually turns this feature off and makes a well-constructed beveled, self-sealing incision.
The femtosecond laser is also able to make perfectly sized and centered circular incision into the lens capsule. This can be important because an improperly sized and centered lens opening can create issues later on where the lens will may tilt or decenter leading to decreased refractive outcomes. Fortunately, most experienced surgeons, like Dr. Swanic, have made thousands of these openings so it is very rare for them to make a lens opening that is decentered to the point that a lens won’t center well or becomes tilted. Femtosecond laser manufacturers and some surgeons commonly tout this feature of the laser to be a strong selling point. We feel it is a nice feature, but studies have not shown that this feature dramatically alters the visual outcome for most patients and it is not a reason that we recommend femtosecond laser technology in cataract surgery.
Laser Assisted Cataract surgery has one very large advantage over traditional cataract surgery in that your surgeon can use the femtosecond laser at the time of cataract surgery to make incisions in the cornea to decrease astigmatism. This can be an excellent option for people with astigmatism under 1 diopter. The Catalys femtosecond laser integrates with our Cassini corneal topographer that measures your astigmatism that we have in our office. The Cassini takes a highly detailed infrared image of your iris that is electronically transferred to the Catalys femtosecond laser. When you are under the laser during cataract surgery it then aligns the laser to your unique iris features to perfectly place cuts that decrease your corneal astigmatism. Unfortunately, as amazing as this technology is, it is expensive, and it is rarely used by most practices. We are fortunate to be able to offer this precision laser assisted cataract surgery at Las Vegas Eye Institute.
Traditional cataract surgery with a small incision, using ultrasound energy to break up the lens, has been the dominant form of cataract surgery in the United States since the 1990s. Prior to this, traditional cataract surgery, was referred to as extracapsular cataract surgery and it was performed through a large incision, without an ultrasound probe. A much larger incision was made and the lens was actually pushed out of the eye in one large piece. This is rarely performed in the United States anymore as the large incision was not as stable and often lead to a very high level of astigmatism after the procedure. If you were to compare this form of surgery to our modern ultrasound procedure the difference was vast.
What are the disadvantages of laser cataract surgery?
There are very few disadvantages to laser assisted cataract surgery. But any procedure in life has some disadvantages. The largest disadvantage is the cost of the procedure. The lasers we use are highly sophisticated advanced computing machines with complex imaging systems along with complex laser energy delivery. This technology took years to develop and requires continued maintenance and calibration to continue to function at its peak. This means that the companies that developed and support the technology need to recoup their investment. Surgeons pay for the machine, they pay for interfaces used for each case, they pay a royalty fee on each case, and lastly, they pay a significant yearly maintenance fee to keep the lasers working. These costs are not paid for by insurance companies and so the cost has to be incurred by the patient.
Another disadvantage to laser assisted cataract surgery is that in some patients the energy delivery can make the pupil that was dilated for the surgery get smaller. A small pupil is actually the highest risk factor for surgical complications during cataract surgery so this can be a significant disadvantage. Fortunately, the majority of patients don’t have this occur and usually when the pupil becomes smaller it is only smaller by a relatively low amount to the point that it doesn’t affect surgical safety.
Which method is best for cataract surgery?
Generally, Laser assisted cataract surgery is superior to traditional manual surgery but it is not always by a large margin. If there was no fee Dr. Swanic would likely use the laser for nearly all cases (except for small pupil cases as described) but for some people the costs don’t provide enough of an advantage to justify its use in every case. For people with significant astigmatism that additional cost may be better placed into using a toric intraocular lens that can more reliably reduce astigmatism when it measures over a diopter. The femtosecond laser is an inferior option to toric lenses for correcting higher levels of astigmatism over a diopter. For people who strongly desire to have near and far vision the laser assisted cataract surgery costs may be better spent on implantation of a multifocal intraocular lens. The laser can be used when placing toric lenses or multifocal lenses but that will also raise the cost of the overall procedure and may not provide any noticeable visual benefit.
Dr. Swanic has performed thousands of cataract surgeries and has an incredibly low surgical complication rate (well under 1%) so he does not recommend laser assisted cataract surgery to increase safety of the surgery very often. We occasionally recommend laser cataract surgery to increase safety when a cataract is very dense because the laser can soften the lens and decrease the amount of ultraound energy needed to remove the cataract. Most studies have shown equivalent safety between manual and laser assisted cataract surgery for cataracts of lower lens density. Dr. Swanic is a corneal specialist, so he also sees patients with a condition called Fuchs’ Corneal dystrophy. This condition weakens the corneas natural pumping system that maintains its clarity. Traditional phacoemulsification cataract surgery can damage these pumping cells through ultrasonic energy waves. In these patients, laser surgery can improve safety by decreasing energy waves that can damage these cells. If you are affected by this condition, we will discuss it with you during a preoperative evaluation.
They have also showed no statistically significant difference in visual outcomes in cases where laser cuts are not used to improve vision. Dr. Swanic typically recommends Laser assisted surgery when he wants to utilize the laser to make precise incisions in the cornea, called limbal relaxing incisions, to decrease preexisting astigmatism. In this case the Laser assisted surgery clearly provides better outcomes when comparing laser cataract surgery to manual.
Is laser cataract surgery worth the extra money?
Laser cataract surgery is definitely worth the money when you have preexisting conditions described in this article such as a very dense cataract or Fuchs Corneal dystrophy where laser cataract surgery confers a safety advantage by lowering the use of ultrasonic energy. Lowering the use of ultrasound energy leads to less corneal swelling which provides a better early visual outcome and can even confer a better long term visual outcome.
Laser assisted surgery is also definitely worth the money when you have a level of astigmatism between 0.5 diopters and 1.00 diopters. The reason is that the laser can precisely place arcuate cuts to lower this level of astigmatism and improve your refractive and visual outcome. If you have less astigmatism after cataract surgery, then you are less likely to need to wear glasses after the procedure.
Laser assisted cataract surgery may prove beneficial in certain cases where a premium intraocular lens is placed, but this value will vary with the type of femtosecond laser your surgeon has access to along with what in office devices they possess to measure corneal astigmatism. At Las Vegas Eye Institute we can import your iris image and topographic (aka astigmatism) data directly into the Catalys Laser at the surgery center. Your imported iris details will then allow the already precise laser to even more accurately place corneal incisions to decrease astigmatism.
Another feature that is nice about this iris registration technology is that it can be utilized to better align a toric intraocular lens. However, Dr. Swanic primarily finds this a useful feature when placing toric lenses in what is called “oblique astigmatism.” The reason for this is that “with the rule astigmatism” is at 90 degrees and the lens is often placed close to vertical while other people will have “against the rule astigmatism” that is at 180 degrees and the lens is essentially placed horizontal. In these cases, the laser placed alignment marks won’t change the location of the lens that dramatically. However, when you go further from 90 or 180 degrees even experienced surgeons can find it difficult to precisely mark the cornea at 52 degrees and then perfectly align the lens. This is much easier to do with iris registered toric alignment marks.
Overall, whether or not cataract surgery is worth the money depends on your unique situation. We are all born different. We have different eyes with different levels of astigmatism, different levels of cataract density, and different preexisting conditions that can all alter how useful laser assisted surgery will be for you. The best way to find out if laser assisted cataract surgery is right for you is to see us for our thorough cataract consultation where all of these factors will be considered, and we will give you an honest opinion on whether or not the femtosecond laser is worth your hard earned money.