Is Laser-Assisted Cataract Surgery Better Than Traditional Cataract Surgery?

Quick Summary

• Laser-assisted cataract surgery is an impressive technology that produces precise results.
• Longer-term studies haven’t been able to show a benefit in patient outcomes from laser-assisted cataract surgery, compared to manual cataract surgery.
• Many eye surgeons who were early, enthusiastic adopters of laser-assisted cataract surgery have now gone back to manual cataract surgery.
• Between my personal clinical experience with laser-assisted cataract surgery, and the results of the most recent research, I don’t find it to be the best option for most of my patients.

 

A Brief History of Laser Cataract Surgery

Lasers are an important tool in the modern eye surgeon’s arsenal.  In 1978, the precursor procedure to LASIK was invented, and today about 700,000 people get rid of their glasses and contacts through LASIK vision correction every year.

Much more recently, lasers have been adapted for use in assisting cataract surgery.  The technology that today is known as Femtosecond Laser-Assisted Cataract Surgery, or FLACS, was originally developed between 1995 and 1997 by researchers at the University of Michigan in Ann Arbor[1].

It was first put into use by cataract surgeons around 2008.  Today, there are several FDA-approved systems that provide laser-assisted cataract surgery, and thousands of cataract surgeons have been trained in their use.  I’m one of them.

However, Medicare and most private insurance plans classify laser-assisted cataract surgery as a “non medically necessary” or elective procedure.  That means that if you decide to have laser assisted cataract surgery, you’re likely going to be paying somewhere around $1,000 per eye in out of pocket costs.

 

Is Investing in Laser Cataract Surgery Worth It?

I’m a strong advocate of investing in your vision, when it makes sense. I’m also a strong advocate of making informed investments.

When it comes to laser-assisted cataract surgery, finding clear answers about the value of that investment can be difficult.

First, let me admit that I admire and like the lasers we use for laser-assisted cataract surgeries.  They’re impressive pieces of equipment.  Each unit costs between $300,000 – $500,000, and they’re made up of precision optics and electronics that enable them to perform parts of the incredibly delicate work of cataract surgery.  I haven’t met an ophthalmologist who isn’t at least a bit of an equipment geek, and I’d be lying if I said I didn’t appreciate the technology of FLACS.

But does that technology lead to better outcomes?

When the manufacturers of those $300-$500K FLACS lasers tout their benefits, they tend to focus on things like precision and repeatability that machine-driven lasers are really good at.  Robots are really good at performing repetitive tasks, the exact same way, every time.

But does that precision and repeatability lead to better outcomes?

If you take a step back, look at a broader cross-section of data and larger independent studies, the clinical benefits of femtosecond laser-assisted cataract surgery aren’t quite so clear.

Let’s take a look at exactly what laser-assisted cataract surgery is, and then we’ll take a closer look at some of those outcomes.

 

The Differences Between Manual and Laser-Assisted Cataract Surgery

Cataract surgery happens in essentially three major steps:

1. A small incision is made in the outer layer of your eye, called the cornea.
2. The old lens, that’s clouded with a cataract, is broken up and removed through this incision.
3. A new artificial lens, designed to give you clear vision, is inserted through that same incision and positioned to give you optimal vision.

Laser-assisted cataract surgery primarily affects steps 1 and 2, creating the small cut and preparing the clouded lens for removal.

Creating the Incision

In both forms of cataract surgery, an incision is made in the outer layer of the eye.  That incision becomes the pathway through which your old clouded lens is removed, and your new artificial lens is inserted.

In traditional cataract surgery, the surgeon uses a scalpel to create that small incision.  In laser-assisted cataract surgery, that incision is created by the laser.

Breaking Up the Clouded Lens

In both forms of cataract surgery, the old clouded lens needs to be broken up into smaller pieces before it can be removed.

In traditional cataract surgery, the cataract is broken up in a process called phacoemulsification with a handheld instrument held by the surgeon called a phaco probe.  This is a small titanium or steel handpiece that vibrates at ultrasonic frequencies and breaks up the clouded lens into smaller pieces.

In laser-assisted cataract surgery, the femtosecond laser is used to prepare the clouded lens to be broken up into smaller pieces for removal, then the process is completed by the surgeon with the phaco probe.

 

Will Laser-Assisted Cataract Surgery Give You Better Vision Than Traditional Cataract Surgery?

The goal of any cataract surgery is to give the best vision possible. So, will investing in laser-assisted cataract surgery give you a statistically significant chance of better vision after surgery?

Probably not.

In 2016, the largest scale comparison of traditional (often referred to as “Manual Cataract Surgery” or “MCS”) vs laser-assisted cataract surgery (often referred to as Femtosecond Laser-Assisted Cataract Surgery or FLACS) to date was published in the journal Ophthalmology[2]. In the conclusions of the study that looked at over 14,000 eyes, the authors write:

“There were no statistically significant differences detected between FLACS and MCS  in terms of patient-important visual and refractive outcomes.”

The term “visual and refractive outcomes” essentially means “how well people see after cataract surgery.”

Another study that included just over 1,600 eyes[3] agreed, though with less certainty due to their smaller sample size, saying, “There may be little difference in vision after laser-assisted cataract surgery compared with standard cataract surgery.”

A 2017 review[4] published by a pair of German ophthalmologists looked at other work and concluded:

“Comparing laser cataract surgery (LCS) with manual cataract surgery (conventional phacoemulsification) based on meta-analysis currently reveals slight differences in refractive and visual outcome. Both methods are extremely successful and safe.”

To translate that into simpler terms, on average, the evidence suggests that patients who have laser-assisted cataract surgery tend to see about as well as patients who have traditional cataract surgery. Not significantly better, or worse.

 

Is Laser-Assisted Cataract Surgery Faster?

Not significantly according to the research, and not in my personal experience.

Some studies have shown that faster surgeries can reduce complications.  So, it’s worth looking to see if laser-assisted cataract surgery is typically faster than manual cataract surgery.

The Popovic, Marko et. al. study that analyzed over 14,000 eyes looked at this and found:

“On average, meta-analysis revealed that effective phacoemulsification time was more than 3 seconds longer for MCS eyes compared with eyes undergoing FLACS […] however, total surgery time was nonsignificantly different between comparators.”

Translated, the part of the surgery that breaks up the clouded lens for removal was on average 3-seconds faster with laser-assisted cataract surgery, but the entire procedure was the same length for both types of surgery.

In my own experience, while laser-assisted cataract surgery can be quite fast at creating incisions and breaking up cataracts, the equipment setup, calibration, scanning and calculation times required in the procedure tend to slow things down so that my overall manual surgeries take about half as long as the laser-assisted cataract surgeries I’ve performed.

Does Laser-Assisted Cataract Surgery Lower the Rates of Complications?

No.

Cataract surgery is one of the safest surgical procedures performed with very low rates of complications.  But “very low” is not the same as “none”.  Every surgery has risks, and most studies show that statistically, cataract surgery results in complications less than 2% of the time.

That same Popovic, Marko et. al. study we’ve been looking at addressed this topic, saying:

“Analysis of safety parameters revealed that there were no statistically significant differences in the incidence of overall complications between FLACS and MCS; however, posterior capsular tears were significantly more common in FLACS versus MCS.”

What does that mean?  Overall, the study didn’t find a statistically significant difference in complication rates between traditional and laser-assisted cataract surgery, but it did find a statistically  significant difference in one specific type of complication: posterior capsular tears.

However, other studies[5] have looked at that specific complication and found no significant difference between traditional and laser-assisted cataract surgery.  Shortly after the Popovic, Marko et. al. study was published, Ophthalmology ran a letter[6] from other respected researchers praising the study overall, but suggesting that perhaps that specific calculation should be rethought.

To put it another way, there isn’t convincing evidence of a difference in complication rates whether you choose traditional, or laser-assisted cataract surgery.

My Personal Experience with Laser-Assisted Cataract Surgery

A few years ago, the studies I’ve been referencing hadn’t been published, and the consensus in the ophthalmology community was that laser-assisted cataract surgery was probably a better option.   More expensive, and possibly slower than traditional cataract surgery, but also probably better.

So, I went through the certification process, leased an expensive FLACS laser, and offered it as an option to my patients.  A few were interested, and we went ahead with a laser-assisted cataract surgery right here in Moscow.

What I found is that my traditional cataract surgery patients tended to have faster recovery times and better visual outcomes than patients that underwent laser-assisted cataract surgery.  All my laser-assisted patients had good vision after surgery, but my traditional cataract patients had better vision.

I fully admit that my sample size was small, so you won’t see my experience written up as a paper in an ophthalmology journal.  However, my experience combined with the latest research has been enough to convince me that laser-assisted cataract surgery isn’t the best option for most of my patients.

What Other Eye Surgeons Say About Laser-Assisted Cataract Surgery

There has been a sea-change in attitudes about laser-assisted cataract surgery in the last few years.  A decade ago, many leading eye surgeons believed that this was the future of cataract surgery.  Now, many of them have changed their minds.

Richard Lindstrom, MD is a recognized authority in the world of eye surgery.  He’s part of a high-volume cataract practice in Minnesota, and a presenter I make sure to catch any time he’s at a conference I’m attending.  He’s also served as a consultant on the advisory board for two companies that make the lasers used in laser-assisted cataract surgery, and even owned equity in those companies. He purchased one of the first 10 FLACS lasers sold in the United States, and integrated it fully into the cataract surgery program in his practice.

In Dr. Lindstrom’s own words[7], “one could argue that few individuals in the world want FLACS to be a greater success than me.”

Nevertheless, Dr. Lindstrom writes that he has now “reduced my personal FLACS usage to zero.”

Like the studies we looked at earlier, in Dr. Lindstrom’s personal experience (and that of 8 out of his 9-surgical partners), laser-assisted cataract surgery simply doesn’t outperform manual cataract surgery in the long term.

While Dr. Lindstrom sees promise in potential future developments in new technologies for laser-assisted cataract surgery, for now, it’s not for him and many other early-adopters of the technology.

Dr. Lindstrom’s current attitude is gaining wider acceptance in the ophthalmology community.  At the 2018 annual meeting of the American Academy of Ophthalmology[8], a group of eye surgeons was given two presentations, one concluding  “FLACS will bring people flocking,” and the other concluding “FLACS will die a slow death.”  After the presentation, the audience voted on which they agreed with, and the majority predicted that FLACS will die a slow death.

While there are many eye surgeons who still use, and prefer laser-assisted cataract surgery, many of my colleagues who embraced the procedure early on have gone back to manual cataract surgery.

What If My Eye Surgeon Recommends Laser-Assisted Cataract Surgery?

Believe them.

Every surgeon has unique strengths, and we all do things a little differently.  It’s entirely possible for one surgeon to achieve better patient outcomes with laser-assisted cataract surgery, and another to achieve better patient outcomes with manual cataract surgery.

If you don’t trust your eye surgeon’s recommendation, you should find a different eye surgeon. Trust is a critical component of the doctor-patient relationship, and studies have even shown[9] that finding a doctor you trust can improve both your outcomes and your satisfaction as a patient.

Personally, I don’t see a benefit to laser-assisted cataract surgery in my own experience and don’t see a body of research to convince me otherwise.  I also know that I have surgical colleagues who have the opposite experience, and who achieve better outcomes with the help of a laser.

If your eye surgeon is one of those colleagues and they believe laser-assisted cataract surgery will give you the best possible outcome, you should believe them.  I have yet to meet a cataract surgeon who doesn’t very sincerely recommend what he or she believes will give his or her patients the best possible outcome.

If I Want to Reduce my Dependence on Glasses or Contacts After Cataract Surgery, Are There Better Options?

In my opinion and experience, yes.

For many patients, toric or multifocal lenses can produce significantly better visual outcomes. Like laser-assisted cataract surgery, these lenses aren’t typically covered by Medicare or private insurance plans.  However, for many patients, the benefits of an advanced lens are well worth investing in.

Another advanced and optional surgical technology I recommend to some of my patients is the use of the ORA System during surgery.  The ORA system uses wavefront technology to analyze the eye during surgery and gives feedback to your surgeon.  I like to describe it as a tool that provides a real-time 2^nd opinion while I’m performing cataract surgery.  It can be valuable in any surgery, but is particularly useful if you’ve had Lasik surgery, if we’re trying to correct for astigmatism with your cataract surgery or implant an advanced cataract lens.

Your Next Steps

If you’re considering cataract surgery, I’d be delighted to give you my in-person, personalized recommendations.

If that sounds like a good option for your eyes, book a cataract consult today.  I’ll look forward to seeing you.

 

Citations

[1] https://crstoday.com/articles/2011-mar/the-origins-of-laser-cataract-surgery/

[2] Popovic M, Campos-möller X, Schlenker MB, Ahmed II. Efficacy and Safety of Femtosecond Laser-Assisted Cataract Surgery Compared with Manual Cataract Surgery: A Meta-Analysis of 14 567 Eyes. Ophthalmology. 2016;123(10):2113-26.

[3] Day AC, Gore DM, Bunce C, Evans JR. Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery. Cochrane Database Syst Rev. 2016;7:CD010735.

[4] Dick HB, Schultz T. A Review of Laser-Assisted Versus Traditional Phacoemulsification Cataract Surgery. Ophthalmol Ther. 2017;6(1):7-18.

[5] Levitz L, Reich J, Hodge C. Posterior capsular complication rates with femtosecond laser-assisted cataract surgery: a consecutive comparative cohort and literature review. Clin Ophthalmol. 2018;12:1701-1706.

[6] Re: Popvic et al.: Efficacy and safety of femtosecond laser-assisted cataract surgery compared with manual cataract surgery: a meta-anaylsis of 14 567 eyes (Ophthalmology. 2016;123:2113-2126), Kohnen, Thomas et al., Ophthalmology, Volume 124, Issue 5, e47 – e48

[7] Lindstrom, R. L. (2018). Acceptance of FLACS in flux. Ocular Surgery News U.S. Edition, July 10. Retrieved from https://www.healio.com/ophthalmology/cataract-surgery/news/print/ocular-surgery-news/{ec1643cd-b70d-4b3a-ae40-f0209d15d1d5}/acceptance-of-flacs-in-flux

[8] Mamalis, Nick MD. Femtosecond laser–assisted cataract surgery: Back to the future.  Journal of Cataract and Refractive Surgery: January 2019 – Volume 45 – Issue 1 – p 1-2 doi: 10.1016/j.jcrs.2018.11.017

[9] Chipidza, F. E., Wallwork, R. S., & Stern, T. A. (2015). Impact of the Doctor-Patient Relationship. The primary care companion for CNS disorders, 17(5), 10.4088/PCC.15f01840. doi:10.4088/PCC.15f01840[/et_pb_text][/et_pb_column]