Laser Surgery for Cataracts

A patient being prepared for cataract surgery. Dennis Macdonald

Cataracts are common among older people, with cataract surgery being one of the safest surgical procedures performed among Americans. If you are exploring treatment for cataracts, you may be interested in laser-assisted cataract surgery.

Traditional cataract surgery is completed using a small blade for an initial incision, followed by a procedure conducted with a phacoemulsifier. A phacoemulsifier is an ultrasound device that vibrates at such a high speed that the cataract is emulsified or dissolved into tiny fragments and gently suctioned out of the eye.

In 2010, the U.S. Food & Drug Administration gave approval to several laser companies for laser-assisted cataract surgery, referred to as femtosecond laser cataract surgery, which augments traditional cataract surgery (but doesn't replace it).

Traditional Versus Laser Cataract Surgery

During traditional cataract surgery, a small incision is made in the periphery of the cornea. The incision is made with a metal or diamond blade held by the surgeon. This self-sealing incision is only about 2 to 2.5 mm long and has a slight vertical and horizontal component so that no stitches are needed.

In laser-assisted cataract surgery, with the femtosecond laser, a surgeon can view a magnified, high-resolution image provided by a built-in OCT device. A peripheral incision can then be made strategically without taking the surgeon's experience into account. This laser-designed incision is safer and seals better than a surgeon-made incision.

The next part of a traditional cataract surgery is the capsulotomy. During a capsulotomy, the surgeon tears a small opening into the front part of the lens capsule that holds the lens and cataract. The surgeon will create this opening by using a needle to tear a small hole in the capsule. The surgeon will then use forceps to tear a circle into the front part of the capsule. This is a critical part of the surgery because the old capsule will remain to hold the new implant or intraocular lens, which is inserted into the eye to replace the old lens-cataract complex.

Capsulotomy

In laser-assisted cataract surgery, the capsulotomy is created in a nearly perfect circular fashion and is completely independent of the surgeon. This circular incision can be centered perfectly to hold the new lens implant in place.

Once the capsulotomy takes place in traditional cataract surgery, the surgeon uses a phacoemulsifier device that uses super high-speed ultrasound to break the cataract into small pieces, which are then gently suctioned out.

With the femtosecond laser, the lens is broken into small pieces as with the phacoemulsifier. The advantage of using the laser is that much less energy goes into breaking the cataract apart, thus reducing potential complications, such as accidentally breaking the capsule, or more severe complications, such as bleeding or retinal detachment.

Intraocular Lens Implant

The next step in the cataract procedure is to insert a new intraocular lens implant to replace the lens that was previously removed. In most patients, the calculated power of the new lens implant attempts to decrease the need for the patient to wear glasses for most distance activities after surgery. If the person having surgery is nearsighted or farsighted, the lens implant will compensate for that prescription.

Occasionally, residual astigmatism will arise, causing reduced vision after surgery. Many surgeons will create small incisions using a blade to compensate for residual astigmatism. Once again, with the laser, more accurate, better placed, laser-induced incisions can be made in an attempt to eliminate astigmatism.

Effectiveness

Traditional cataract surgery remains a very safe and effective procedure and the complication rate is very low. However, most cataract surgeons believe that eventually all cataract surgery will be performed using a laser.

Today, laser-assisted cataract surgery will likely shine most brightly in the premium multifocal or presbyopia-correcting implant surgical specialty. These premium multifocal implants lessen the dependence on post-cataract corrective eyeglasses by not only correcting distance vision problems but also intermediate and near vision. These implants are designed to enable the patient to only require eyeglasses on a very limited basis. This type of surgery requires greater precision, hence the femtosecond laser.

Drawbacks

One of the few drawbacks of laser-assisted cataract surgery is a cosmetic concern. People who undergo the laser procedure usually develop more redness the day after surgery, due to docking of the instrument during the surgery.

Additionally, there are some complications from laser surgery that are not inherent in traditional cataract surgery, such as capsular tags.

Not everyone will qualify for the procedure, as well. Pupil dilation issues specifically are considered a disqualifying factor, along with other problems.

Cost may also be a drawback. Procedure costs are higher for laser surgery, due to the higher cost of the additional equipment necessary. Medicare and insurance companies unfortunately do not cover laser assisted cataract surgery.

Finally, although each step of the laser procedure is probably safer, the whole procedure itself takes much longer, increasing the risk for complications or infection. In the skilled hands of the cataract surgeon, traditional cataract surgery can take as little as 10-15 minutes for the actual surgery itself, with laser surgery taking significantly longer.

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  2. Davis G. The Evolution of Cataract Surgery. Mo Med. 2016;113(1):58-62.

  3.  American Academy of Ophthalmology. Adjustable IOL Could Help Some Ditch Their Glasses After Cataract Surgery. Published February 16, 2018.

  4. Nagy ZZ. New technology update: femtosecond laser in cataract surgery. Clin Ophthalmol. 2014;8:1157-67. doi:10.2147/OPTH.S36040

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