laser-assisted cataract surgery

[nvgolde]

I am highly myopic with -16 in each eye & have astigmatism.  I will be having cataract surgery and have a choice of with or with-out laser-assisted surgery.  Am I likely to have a better outcome using the laser?  It will cost more.  
Thanks!

[Luvtoski]

Very impressive, helpful exchange of information.  Thank you all.

[Timothy D McGarity, M.D.]

It has nothing to do with the retina. Increased phaco time would potentially be detrimental to the corneal endothelium. Even with all ultrasound (no laser) the phaco time and program itself are rarely significant.

I don't have the studies, but some show increased risk of capsular rupture with femto phaco…these were early studies and it is thought that the rate of capsular rupture is lower with new patient interfaces.

Re toric IOLs for highly myopic people…it depends on the power your eye needs. Toric IOLs go down pretty low and if not low enough then you can have a toric with a regular piggyback IOL or you could just go with a lasik touchup afterwards to get the remaining astigmatism and myopia.

You are well informed and I wish you the best

[flossy93]

Thank you for the clarification, Dr. McGarity.  I especially appreciate your specific citation of the equipment you feel gives the most accurate preoperative measurements (the LenStar).

With regard to your comment concerning toric lenses being more reliable than corneal limbal relaxing incisions, is it possible to obtain toric implants for patients with a contact lens prescription of -16?  I don't know if there is any reduction in replacement lens options for patients at the edges of the refractive correction bell curve (as there is for traditional contact lenses).

I should have been more detailed in my comment that it is possible not to need any ultrasound phacoemulsification to break up a cataract with the laser procedure.  My understanding is that it is possible that this can be achieved (see reference #1 below), but that at a minimum there appears to be a significant reduction in the length of time the ultrasound probe is activated compared to traditional cataract surgery, even if the time is not reduced to zero.  The studies refer to this time as 'EPT' or 'effective phacoemulsification time.'

I came across abstracts for at least two recent publications citing the decrease in effective phacoemulsification time in the laser based procedure compared to traditional cataract surgery.  One of these two articles notes than 30% of patients had zero effective phacoemulsification time with their laser based cataract break-down, and that overall there was a 96% reduction in phacoemulsification needed compared to the traditional approach.

Here is a link to the journal abstracts for anyone wishing to read them:

Ophthalmology, May 2013:  "Toward zero effective phacoemulsification time using femtosecond laser pretreatment"
http://www.ncbi.nlm.nih.gov/pubmed/23465860

Journal of Refractive Surgery, Dec 2012:  "Effect of femtosecond laser fragmentation on effective phacoemulsification time in cataract surgery"
http://www.ncbi.nlm.nih.gov/pubmed/23231739

Two doctors I have asked both feel that the large decrease in ultrasound exposure, even if it is not zero, makes the laser procedure safer for the retinas of highly myopic patients.  It's interesting to read that you feel it is no better than the traditional approach.

[ValveJob]

I have read several articles that say that with the laser-assisted cataract surgery, there is less insult to the retina since the ultrasound is only used at the end.

Since I am a person with degenerative myopia, anything that could reduce the risks for me is important.  Although I will be speaking to my RS soon about this, I like to get all the input I can about the subject.

[Timothy D McGarity, M.D.]

Laser Assisted Cataract Surgery is no better than regular cataract surgery. They both utilize phacoemulsification. To imply no ultrasound is used is false as the surgeon still needs to place the phaco probe into the eye. A toric lens is more reliable than cutting the cornea with limbal relaxing incisions, but if a small amount of astigmatism correction is needed then I would say go with Laser Assisted LRI. The best way to ensure accuracy is to have really good preoperative measurements. In my clinic I use the LenStar because it truly gives better measurements than the IOL Master. I don't yet use the ORA during surgery (intraoperative wavefront), but I will be using in the near future. This device will tell the surgeon if the IOL used is accurate while you are on the table. Furthermore, there is no more precise way to surgically correct the vision than laser vision enhancement after cataract surgery. You can safely have LASIK or PRK after cataract surgery to 'fine tune' your vision. I think overall there's a lot of wrong information about laser assisted cataract surgery. It's great, but to imply it's better is wrong. I hope this helps.

Best wishes,
Timothy D. McGarity, Medical Doctor, Ophthalmologist

[flossy93]

I am also highly myopic (just increased contacts from -14 to -14.5/-15.0) and was told both by my OD and a cataract surgeon that the laser-based procedure is safer for patients prone to retina detachment/problems.

Traditional cataract surgery uses ultrasound energy to break up the cataract.  It is discharged within the eye via an ultrasound probe inserted near the clouded lens.  The ultrasound waves can propagate through the vitreous fluid within the eye and bounce off the retina, increasing the chance of loosening or disturbing it.

In the laser procedure, laser energy is targeted at the exact depth of the clouded lens and can be programmed to precisely cut the cataract and break it up for extraction.  The laser energy is less likely to propagate elsewhere in the eye and disturb the retina.

Another laser procedure benefit is that the machine can precisely map and cut limbal-relaxing incisions in the cornea to diminish any astigmatism you may have.  If you have no astigmatism this won't be a benefit in your case.  These can also be cut by hand by the traditional surgeon, I think.

Lastly, if you plan to have a multi-focal or accommodating lens implanted, the laser can more precisely create the pocket within the lens capsule for optimal placement of a multi-zone lens.  At your prescription level this may not be an option so again, may not be a benefit in your case.

There was a recent paper published citing better outcomes with the laser cataract procedure by doctors who had done a lot of laser-based procedures.  Iff you go the laser route be sure to choose a surgeon who isn't just starting out using the laser for cataract surgeries.

Recently I traded emails with a patient who was a -20+ myope and who had traditional cataract surgery this past summer with no retina problems, so it's certainly possible.  Only you - and the doctors with whom you consult - can tell you if the potential benefit in retina safety is worth the extra expense of the laser-based procedure.  Good luck!