What is the best method for cataract surgery?
My grandmom needs cataract surgery. The doctor recommended Femtolaser cataract surgery or conventional cataract surgery. May I know the pros and cons of both? Cost is not an issue, I just want the best results and outcome for my grandmom as I read that cataract surgery carries a 1 in 1000 risk of blindness.
Most of the time, cataract surgery is done using phacoemulsification ie using a special hollow probe vibrating at ultrasonic frequency (20-40000 times a second) to break the cataract up and remove it through a small 2.2mm corneal incision.
About 5-6 years ago, femtosecond lasers became available in Singapore to assist with cataract surgery. They only 'assist' the surgeon to do certain parts of the procedure eg. making the corneal incision, making the hole in the front of the lens capsule and pre-cutting the cataract. All of these functions are done 'manually' with standard phacoemulsification and have been done this way for many years with no problems except in rare cases, such as those with very weak zonular ligaments. Even with the use of the femtosecond laser, the surgeon still needs the phacoemulsification machine to remove the cataract.
Suffice to say interest in the femtosecond laser seems to have waned recently. Many doctors who were initially enthusiastic are now much less so, for the following reasons:
1. Outcomes (both visual and in terms of complication rate) are no different between femtosecond cases or standard cases.
2. Some studies even show a slightly higher complication rate when femtosecond lasers are used, compared to standard phacoemulsification.
3. Longer surgical time when the femtosecond laser is used.
4. Increased surgical cost.(-this would be OK if it led to a better outcome, but it does not; ie the outcome is not worth the increase in cost)
Overall, my feeling is that use of the femtosecond laser is not worthwhile in the vast majority of cataract cases.
In any case, please be reassured that the risk of blindness is far, far less than 1 in 1000 for a person undergoing catract surgery. Cataract surgery nowadays is very much routine day case surgery, with fast visual and surgical recovery and an extremely low risk of complications.
As far as visual outcome is concerned, the choice of lens implant is likely to have a far greater influence on the post-operative visual experience (than whether the femtosecond laser is used), and you and your grandmother should discuss the various options with your doctor.
The current gold standard of cataract surgery is done via phacoemulsification with micro-incisions as small as 1.8mm to 2.2mm. In recent years, the use of femtosecond lasers in cataract surgery has been introduced for the hope of improved precision in certain steps of cataract surgery.
For many surgeons, the view is that femtosecond surgery, though it may be applied to most cases of cataract surgery, has a comparative advantage to non-laser techniques only for specific types of cataracts (e.g. mature dense cataracts).
In the majority of cases, cataract surgery results are excellent with or without the use of femtosecond laser. Hence, many surgeons are rather selective as to who should have surgery using a femtosecond laser as it does entail greater costs and lengthens the overall time of the surgery for the patient.
There has been much hype lately about touting the laser as vastly improving results of cataract surgery and that it is a “bladeless” technique. In many ways, the laser simply does the job of the steel blade. Hence, the term “bladeless” is rather meaningless in this context as both techniques require incision wounds to be created and for the surgeon to enter the eye. As a result, with or without the femtosecond laser, the surgeon still has to work within the eye and the risk of complications are not removed. To most skilled and experience surgeons, little or no improvements in their surgical results have been seen with the use of femtosecond lasers in cataract surgery.
Also note that all femtosecond lasers in the market currently are still in their first generation. Could technology in femtosecond lasers improve to make a more compelling case for greater widespread use? Yes, certainly. So I too am eagerly awaiting to review the capabilities of the second generation of femtosecond lasers.
I applaud your interest in finding the best possible treatment for your grand mother. My advice to you is to seek out the best surgeon you trust and let them advise you on the best course of action. The best direction may not always mean the highest cost option which some may lead you to believe.
I wish you all the success with your grandmother's treatment.
Dr David Chan
Personally I had been performing phacoemulsification with excellent results with and without the femtolaser. The benefit of the laser is that it can reduce the ultrasound energy required in conventional phaco, and it has advantage in being quicker in performing and more accurate in sizing the lens capsule opening, a step that allows access to the lens. In very white cataracts this may reduce complication rate.
I actually presented a continuing medical education talk to my fellow doctors showcasing some of the cases of femtolaser cataract surgeries I performed before to my fellow doctors 2 years ago at Gleneagles Hospital.
A Singapore study found that the laser cataract surgeries improved refractive outcome by less than 0.25 diopter, that is 25 degrees of power. Which is hardly necessary to change glasses prescription for.
At last Saturday’s Business Times health seminar, i also spoke about my current perception of the role of femtolaser cataract surgery. I could not agree more with surgeons who stand up for financial prudence on behalf of their patients. The same resources channeled into femtocataract can be channeled into better lenses, better measuring devices to improve lens power calculation and smaller wound sizes (I strongly advocate reducing it as much as possible and routinely offer 1.8mm incision for suitable cases). I firmly believe the latter 3 elements in combination play a much bigger role in improving the refractive results of routine cataract surgeries.
In general I see advantage in femtocataract only in select cases such as dense cataracts, white cataracts and shaky cataracts. Having said that, I also know for a fact that some of the top cataract surgeons in the world had tossed out their femtocataract lasers even for the most complex cases.
Final case in point: my last “conventional” phacoemulsification patient saw 6/6 in both eyes ( it was a bilateral case) at day 1 after op and you would not be able to tell she had her eye operation the day before. In comparison, my last femtolaser cataract surgery patient also saw 6/6 at day 1 after op, but her eye was very slightly pinker due to the suction imparted by the laser interface, and her insurance company was poorer by about 20% of the total bill.
So do try to sieve through some of the hype and marketing ploy which unfortunately is pervasive even in medicine, and I wish your mother a successful cataract surgery! Cheerio!