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When Is Laser Cataract Surgery Worth The Cost

When Is Laser Cataract Surgery Worth The Cost

In a perfect world, all cataract surgery would be laser cataract surgery. It is a fantastic technology that has advanced the way we remove cataracts. But laser cataract surgery does come with an extra monetary cost.

For many people having cataract surgery, having laser cataract surgery may not be worth the extra cost. Traditional cataract surgery still performs very well. But for those looking to get out of glasses or have upgraded lenses, laser cataract surgery can improve those results.

Laser cataract surgery is also very useful for those with dense cataracts; avoiding excess energy that can potentially damage delicate structures in the eye.

So although laser cataract surgery may not be superior to traditional cataract surgery for everyone, there are a few certain use cases that it can outperform the manual methods.

But before we get into that, let’s first look at the steps of cataract surgery that a laser can replace.

What Is Laser Cataract Surgery

During cataract surgery, the cataract is removed and replaced with a new artificial lens. To understand how laser cataract surgery works, we first must understand the steps of cataract surgery.

  1. Before cataract surgery begins, incisions must be created within the cornea. This is a step the laser can perform.
  2. The cataract is contained within a capsule within the eye. This capsule is preserved during cataract surgery for the new artificial lens to sit in. Thus, a circular opening must be made in this capsule. This is also a step the laser can perform.
  3. Saline is injected around the cataract to loosen it from the capsule. This step must be done manually.
  4. The cataract is broken up into small pieces through a process called phacoemulsification. This step can be replicated with the femtosecond laser using laser energy instead.
  5. The cataract is removed through a tiny vacuum. This step must also be done manually.
  6. The artificial lens is placed inside the eye and in the capsule. This step can only be done physically by the surgeon.

So technically the laser doesn’t perform the ENTIRE surgery. It only assists the surgeon with the surgery. This gives it the more accurate name Laser Assisted Cataract Surgery

Comparison Of Laser Cataract Surgery Vs Traditional

Lasers can’t replace surgeons in cataract surgery. So is there any point in a laser?

It’s a fair question and has led to countless studies over the past decade and a half that looked at that exact question.

And in fact, most of the final assessments have been that laser cataract surgery and traditional manual cataract surgery are pretty equivalent!

  • Manual cataract surgery and laser assisted cataract surgery generally have the same outcome in vision.
  • And overall, there doesn’t appear to be any vast differences in safety by using a laser.

The decision to use a laser or not for cataract surgery is also muddied by the economics of it. Laser cataract surgery doesn’t come without an extra added cost. Obtaining a laser that can perform cataract surgery isn’t free. In addition, insurances don’t cover this extra service. Thus this extra cost is passed on to the individual having cataract surgery.

This seems like a deathknell for laser assisted cataract surgery!

But in fact, laser cataract surgery is still used frequently today. There are just certain situations that benefit more from laser assisted cataract surgery than others.

Best Uses Of Laser Cataract Surgery

The demands of today’s cataract surgery are higher than ever. And there are certain strengths of laser cataract surgery that are suited to meet those demands. So in what situations may laser cataract surgery be worth the cost?

Getting Out Of Glasses or Upgraded Lens

This is probably the biggest reason to get laser cataract surgery.

There are two things that the femtosecond laser does during cataract surgery that outperforms what can be done manually.

  • The femtosecond laser does a better job correcting astigmatism than any manual techniques
  • The femtosecond laser creates a better opening into the capsule

Both of those two things can affect vision. If you are planning on wearing glasses after cataract surgery, then using a laser for those steps probably won’t provide much benefit for you. But if you are looking to get out of glasses, then laser cataract surgery can provide benefits.

Astigmatism

Correcting astigmatism is probably the best use of laser cataract surgery.

When you have astigmatism, your cornea is shaped more like a football than a basketball. (also check out The Simple Explanation of What Is Astigmatism to learn more). This astigmatism must be corrected with a different type of lens to correct vision properly. Your pair of glasses may already contain lenses which correct your astigmatism.

But astigmatism can also be corrected with cataract surgery.

Low amounts of astigmatism are corrected through something known as limbal relaxing incisions. These are incisions made perpendicular to the steep part of the football-shaped cornea. They help relax that steep part to turn the cornea into a basketball-shape. A laser can make these incisions much more precise and accurate than what can be done without a laser. This means better astigmatism correction.

Higher amounts of astigmatism are corrected using a special lens called a toric lens. This lens is rotated within the eye to line up with the steep part of the football-shaped cornea. If this lens isn’t lined up perfectly, the astigmatism correction is less effective. Lasers can create a marker to perfectly line up the toric lens. Lasers systems can even compensate for any rotation of the eye to get things as accurate as possible.

Better Capsule Opening

After the cataract is removed, a new artificial lens is placed into the capsule. This artificial lens unfolds to fill the capsule. But the position of this lens is also influenced by the opening to the capsule.

If the capsule opening doesn’t equally and fully cover the lens, one side of the lens can tilt. This tilt can create subtle distortions in vision. Light that enters the tilted part of the lens is focused at a slightly different spot than the opposite site of the lens. This creates a distortion called “coma”. This can cause a slight blurring of vision.

How do you create a capsule opening which is exactly the same and covers the lens perfectly over and over again? The only way is to use a laser.

Perfect round opening to capsule created by laser (blue circle to highlight opening)

Perfect round opening to capsule created by laser (blue circle to highlight opening); image by H. Burkhard Dick & Tim Schultz, used under CC BY 4.0 / modified from original

Having a capsule opening created by a laser can reduce those subtle distortions to improve quality of vision.

Importance for Upgraded Lenses

While it's great to have no astigmatism and less distortions in vision, for standard cataract surgery it doesn’t make a huge difference in vision - especially if you plan on wearing glasses to correct astigmatism.

It does become important, however, when considering special upgraded or premium lenses to get out of glasses completely.

Special lenses exist which can reduce or eliminate not only glasses for distance vision but also for reading vision as well. (Check out Your Complete Guide Of Lenses For Cataract Surgery to learn more).

These special lenses use various optical principles to do more than what is capable of from a normal lens; a single lens is capable of refocusing light simultaneously for up close, distance and computer distances.

While these lenses are an impressive technology, they are more sensitive to anything that blurs vision. This includes astigmatism and distortions in vision. Combining these lenses with laser cataract surgery is a great way to optimize the prescription and vision as much as possible for the best vision with these lenses after cataract surgery.

Very Dense Cataract

This is the second biggest reason to get laser cataract surgery.

The eye is full of sensitive structures. One such structure is a thin layer of cells on the inside of the cornea called endothelium. These cells pump water out of the cornea to keep it clear.

Endothelium on bottom of the cornea

Endothelium on bottom of cornea; Image by StemBook (CC BY 3.0) / modified from original

When we are born, we have as many endothelial cells as we will ever have in our lifetime. These cells don’t regenerate.

The concern is if we lose too many of these cells. If the number of these cells fall below a critical level, the cornea becomes swollen with water and the vision becomes blurry. A situation that can only be fixed with a cornea transplant to replace those cells.

We do gradually lose some each year but not enough to cause any problems. But we can lose more during certain events (ie surgery) in our life.

Phacoemulsification damages those endothelial cells

Using ultrasound energy to break up a cataract will damage and kill off endothelial cells. The more ultrasound energy used to break up the cataract, the more damage that can result to the endothelial cells.

Fortunately, laser assisted cataract surgery is effective in both:

  1. Reducing the amount of phacoemulsification ultrasound energy. Because the femtosecond laser energy can be used to divide up the cataract, much less ultrasound energy needs to be used.
  2. Reducing the amount of endothelial cell loss. This is a direct result of the less ultrasound energy needed for laser assisted cataract surgery.

Best situations to avoid excessive ultrasound energy

Fortunately, today’s cataract surgery is sophisticated enough to avoid significant damage from the phacoemulsification ultrasound energy to the endothelium. Most cataracts aren’t dense enough where this energy becomes a concern. But there are situations where laser cataract surgery can be more protective of this delicate layer.

  • Dense Cataracts. This is the most straightforward example. The worse the cataract, the more it will benefit from the energy savings from laser cataract surgery.
  • Already Weak Cornea. If you don’t have a healthy endothelium (such as from a condition called Fuchs’ Corneal Dystrophy), then you want to make sure you do everything to prevent it from getting worse. Avoiding as much phacoemulsification energy as possible becomes beneficial to avoid a potential need for a transplant in the future.
  • Farsighted Prescription. This one is a little more subtle. People with farsighted prescriptions tend to have short eyes. A short eye means that the cataract is being broken up with the ultrasound energy closer to cornea. This means the energy used during cataract surgery has a greater effect on the cornea than would be with a longer eye.

Summary

For many people having cataract surgery, having the procedure assisted by a laser isn’t going to lead to dramatic changes afterwards. Vision and safety are good regardless of whether the procedure is done by laser or via traditional manual methods. But for those looking to get the best vision possible and especially for those desiring to get out of glasses with upgraded lenses, laser cataract surgery offers ways to correct astigmatism better and reduce extra distortions in vision. Laser cataract surgery is especially good for those with dense cataracts to reduce extraneous energy in the eye and prevent damage to sensitive structures in the eye.

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