Laser Cataract Surgery

Laser Cataract Surgery

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2 Types Of Cataract Surgery

1 Year After Cataract Surgery

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.

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.

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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.


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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.

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Laser eye tracking was the first major advancement in LASIK surgery and it was an important one, because it is instrumental to the implementation of further technological advancements that followed it. Eye tracking essentially allows the laser to follow the eye. Many people don’t realize this but the original LASIK lasers actually didn’t have any of the advanced eye tracking technology that is available today. In fact, the older lasers didn’t have any eye tracking, period.

That isn’t to say they were just firing randomly, but they essentially relied on having the patient fixate on a light and not move their eye during the surgery. If the patient moved their eye, the surgeon could stop the laser and remind them to fixate on the light. This may sound primitive, and to some extent it was, but we need to realize that the original LASIK lasers did not fire at as a high a rate as the ones we have today, meaning that the surgeon had more time to stop the laser if eye movement was detected.

Also, the only LASIK ablation profile available on the first lasers was for myopia, or nearsightedness, which is a treatment that essentially flattens the central cornea. If this type of treatment is mildly decentered, it often doesn’t affect a patient’s vision substantially, especially if only a small fraction of the spots is off target. This is not the case for hyperopia or farsighted treatments where lasers are fired in a ring around the center of the visual axis instead of just firing in the center of the cornea.

One thing I can tell you, and often reiterate to all of my patients, is that all modern lasers have eye tracking. If a patient moves their eye during the procedure the most common thing that occurs is that the laser will simply shift its firing pattern to the eye’s new location. However, if the patient moves their eye too far, then the laser will simply stop firing. If this occurs, I will stop and reassure the patient, let them find the fixation light again, and then the procedure can proceed normally. The laser utilized at Las Vegas Eye Institute, called the Visx S4 IR, not only has active eye tracking, it also has a technologically advanced feature called “iris registration”. This technology is linked to the preoperative testing machine at our practice called the Visx iDesign. The iDesign takes an infrared picture of your eye that is transferred to the laser prior to your procedure. Then when you are under the laser, I personally capture a new picture of your eye that is matched to your preoperative picture. Why do I do this? The reason is our eyes are known to rotate when we lie down on our back, this can be a negligible amount (say 1-2 degrees) but it can also be a more significant amount (such as 6-10 degrees) that will make astigmatism correction less accurate. The “iris registration” technology that we have at Las Vegas Eye Institute coupled with the high resolution “wavefront guided” LASIK ensures that the precise treatment we captured before the procedure is properly lined up when your eye rotates even a fraction of a degree when under the LASER, which leads to more optimal outcomes.

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What is Wavefront?

Wavefront is a key topic to understand when we are discussing modern LASIK because nearly all of the procedures done these days are either “wavefront guided” or “wavefront optimized”. A wavefront is simply a light beam that is analyzed after it exits your eye. Our iDesign device specifically sends an infrared beam (that you cannot see) through your eye and then an advanced sensor picks up and analyzes the infrared beam when it exits your eye. A wavefront is unique to your specific eye and when it is captured it shows us precisely how your eye tends to distort light. A nearsighted patient will have a completely opposite wavefront capture compared to that of a patient that is farsighted.

Astigmatism is also captured up on a wavefront. Of course, we don’t capture wavefronts merely to determine if a patient is nearsighted, farsighted, or has astigmatism. All of those things can be determined with a much more basic device called an autorefractor and then confirmed by a doctor or technician using the typical “which is better 1 or 2” device called a phoropter. The reason we actually began to capture wavefronts was that in the early 2000s we were aiming to give patients “superhuman” vision by correcting things beyond what glasses were capable of correcting. Nearsightedness, farsightedness, and astigmatism (things that can be corrected with glasses) are referred to as “lower order aberrations.” Wavefront goes beyond this to try to correct more subtle optical abnormalities called “higher order aberrations” which primarily include things called coma, trefoil, and spherical aberration.

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OK, I think I understand what a wavefront is, now what is wavefront optimized LASIK?

Wavefront optimized LASIK is a great technology that was popularized by a laser originally called an Allegretto but is now utilized in the United States primarily on the Alcon Wavelight Platform. I was trained using this technology during my fellowship at UCLA and have used it for many years with great results. However, its “wavefront” terminology doesn’t have anything to do with a wavefront capture device. It only has to do with the way all treatment plans are created with the laser. The treatment plan is initially input into the laser in the form of nearsightedness or farsightedness with or without astigmatism.

This treatment plan is actually written just like your glasses or contact lens prescription. Wavefront optimized LASIK then takes into account the typical preexisting amount of “spherical aberration” in the general population of patients along with the amount of spherical aberration that LASIK normally induces. With Wavefront optimized LASIK, the laser is programmed to fire additional pulses to correct for this typical preexisting and induced spherical aberration which is also known as “wavefront error”. Accounting for and correcting this wavefront error was a great advancement in LASIK technology. Patients get great outcomes and this is the reason I’ve used wavefront optimized LASIK technology on countless patients with both the Wavelight 400 and the newer Wavelight EX500 platform.

What is Wavefront guided LASIK?

Wavefront guided LASIK is LASIK that corrects “higher-order aberrations” along with “lower order aberrations”, i.e., nearsightedness, farsightedness, and astigmatism. Wavefront guided LASIK can go a step beyond wavefront optimized LASIK because it is actually attempting to correct several other “higher-order aberrations” other than just spherical aberration that was discussed above. Higher order aberrations known as coma and trefoil cannot be corrected using general population data because coma and trefoil by their very nature are unique to each individual patient’s eyes. So if you want to correct these higher order aberrations, it is necessary to test for them with a wavefront capture device on each patient you want to treat. The original wavefront capture device (the device that was used to perform LASIK on my own eyes in 2010) was called the Visx Customvue. It was an amazing device at the time and consisted of something known as a Hartmann-Shack aberrometer that was able to detect things like trefoil, spherical aberration, and coma. The Customvue then took this data and created a treatment plan to correct these aberrations along with the lower order aberrations of nearsightedness, farsightedness, and astigmatism. It was very advanced for its time and even captured an iris image that was transferred to the laser for “iris registration” as discussed above. There has since been a further advancement in technology with the iDesign 2.0 which is the device used to capture each patient’s individual data at Las Vegas Eye Institute.

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LASER Vision correction is an amazing procedure and there are many excellent places to get it done. However, we know that when it comes to your eyes that it’s not only normal, but expected, to be nervous about getting this procedure done. We want to put you at ease and let you know what we would look for in a refractive surgery practice.

An experienced and well-trained surgeon. Notice that we didn’t just say experienced. We find that many practices talk about how many “cases” they have done. However, what you really care about is how many they have done right. At Las Vegas Eye Institute Dr. Swanic has been doing LASIK procedures for 10 years since he began his Cornea and Refractive surgery fellowship at UCLA. He is certified to use both the Visx and Wavelight platforms but this does not mean he just did a weekend course (that is actually all it takes to become certified.) He did a year of fellowship training with Rex Hamilton M.D. at UCLA where he not only learned the best techniques to perform the procedure but more importantly the best way to evaluate people BEFORE performing the procedure. At a tertiary care facility like UCLA, that sees patients from all over the world, he was able to see the very rare complications of refractive surgery and learn how to avoid them.

Up to date preoperative testing equipment. People sometimes feel our screening for LASIK can be a bit exhaustive, but of course, when something is as important as your eyesight you don’t want shortcuts. All patients at Las Vegas Eye Institute undergo an extensive evaluation of the shape and curvature of their cornea (the structure where LASIK is performed). We no longer use conventional corneal topography as we find it can give variable results that can be hard for even the most experienced surgeon to properly evaluate.

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