Is the Femtosecond Laser worth it for cataract surgery?

[desm0nd]

This will cost me an additional $1000 per eye. Just wondering what everyone's thoughts are on if its worth it for cataract surgery.

Thanks

[SoftwareDeveloper]

I just noticed another article with surgeons giving their differing views of laser cataract surgery, with the skeptical one noting:

http://crstoday.com/2016/01/is-less-better/
"In a study of 4,000 patients that compared laser and standard cataract surgery, the refractive outcomes were similar, but the rate of complications was higher across the board in the laser group: 8.4 times higher in terms of anterior capsular tears, 2.4 times higher for posterior capsular tears, a 12-fold greater risk of corneal haze, and a fivefold greater need for iris hooks or the Malyugin Ring (MicroSurgical Technology) due to miosis in the laser versus manual group.3 The FLACS ESCRS Study also found a higher incidence of complications with laser versus standard cataract surgery. Investigators for that study concluded, “Femto patients have worse post-operative visual acuity. Femto patients have more post-operative complications and more patients with a post-op visual acuity worse than pre-op.”4
....Standard cataract surgery takes significantly less time than laser cataract surgery,11 and it carries a lower risk of complications.3,4 The former remains the gold standard. "

[JohnHaganMD]

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[achillea]

Well, that's interesting--and a little discouraging.  Maybe these numbers will change as Femo surgeons accumulate patient hours of experience?

[achillea]

Well, that's interesting--and a little discouraging.  Maybe these numbers will change as Femo surgeons accumulate patient hours of experience?

[JohnHaganMD]

There are a lot more moving parts and extra maneuvers in femtoseconod laser cataract surgery than standard cataract surgery. Plus the instruments and the surgical experience are in the early phase. It was the same way when phacoemulsification was introduced to replace planned extracapsular surgery. For the great majority of people, especially where money is a concern the extra cost is simply not worth it.

[JohnHaganMD]

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[SoftwareDeveloper]

The comment about a surgeon not accepting Medicare leading you to think they won't pay him what he thinks he is worth seems backwards. Medicare doesn't pay more for high quality doctors, so if anything that should suggest valuing his opinion more, especially on this particular issue since some fear surgeons push for laser cataract surgery precisely to make more money because Medicare doesn't pay for it, and this is one who isn't pushing it.

I've worked at the leading edge of the computer world for a few decades,  in research and startups. It tends to be common knowledge that many new technologies eventually prove themselves, and some are adopted later than they should be due to fear of new things,  but that some others  are initially  bought into prematurely based on unjustified hope when its questionable if they have yet proven their benefits beyond existing technologies. In my case I chose to expend the effort to travel abroad to get a newly released IOL not approved in this country since the benefits seemed justified, but they didn't in the case of laser cataract surgery at the time.. and I'm unsure they do now.

This is a few minute video from the recent ASCRS conference with a surgeon talking about:

http://eyetube.net/series/daily-coverage-san-diego-2015/ohedo/
"The Ethics of Femtosecond Laser Cataract Surgery"

And discussing the issue  for instance of   being careful for instance to distinguish between the differing personal beliefs of surgeons, vs. what the evidence shows. The wording difference can be subtle, and patients are often not going to be paying close enough attention to realize the distinction they are trying to make.  

An article from January talking about the economics of the issue and mentioning that most of the claimed  "benefits" are purely theoretical assumptions that haven't been demonstrated to have a benefit from the patients perspective:

http://www.medscape.com/viewarticle/856001_1
"The debate can be framed from a technical standpoint; does FLACS result in a measurably better surgery, with better results?[8,9] Current studies show some theoretical advantages in terms of the circularity of the capsulorrhexis, predictability of the effective lens position calculation, decreased total ultrasound energy with resultant decreased endothelial cell injury, and reproducibility of corneal incisions including peripheral corneal relaxing incisions.[10,11] Although there is a large multicenter French trial underway currently,[12] there is a dearth of published studies showing actual improved outcomes. At the very least, FLACS does not seem to have inferior outcomes to traditional cataract surgery once the initial learning curve is mastered.[  ...
The literature does show a significantly higher cost for FLACS. As this cost can be passed on to patients under Medicare rules, there is the potential for increased physician revenue, which can be a motivator for adoption of this new technology.  "


A review article:

http://www.reviewofophthalmology.com/content/i/3190/c/53363/
" Femtosecond Cataract: What the Data Says
A review of how femtosecond-assisted cataract surgery is faring in the literature.
“I think most surgeons would recognize that femtosecond laser cataract surgery is brilliant—as long as they didn’t have to pay for it,” jokes Hyderabad, India, surgeon Kasu Prasad Reddy. Though Dr. Reddy uses the femtosecond in his practice, he acknowledges that his fellow surgeons have to think long and hard about investing hundreds of thousands of dollars in a device when they already get excellent results from conventional phacoemulsification. This thinking logically leads them to wonder what data exists on femtosecond that might shed some light on the kind of results they could expect with the new procedure. To help surgeons answer this question, following is a review of the major femtosecond research from the past several years, as well as thoughts from researchers on their findings."

For example, some large studies:

http://www.eurotimes.org/node/1685
" The study examined 4,080 consecutive cases operated by five surgeons at a single regional day surgery centre from May 2012 through to November 2013, Dr Vote reported.

“The visual benefits of laser cataract surgery have yet to be clearly established. As all of us are aware, cost effectiveness or the lack thereof for laser cataract surgery remains a significant obstacle to the uptake of this technology,” Dr Vote said"

A different study:

http://bmctoday.net/crstodayeurope/2014/10/article.asp?f=news
"LACS DID NOT OUTPERFORM ROUTINE PHACO

Preliminary results of the ESCRS/EUREQUO Femtosecond Laser-Assisted Cataract Surgery (FLACS) study showed that laser-assisted cataract surgery (LACS) is as good as routine phacoemulsification, but currently does not outperform it, Peter Barry, FRCS, said during the XXXII Congress of the ESCRS meeting in London.1

The FLACS study, funded entirely by the ESCRS without the participation of industry, represents the first time that the outcomes of LACS have been compared with the outcomes in matched patients undergoing routine phacoemulsification in terms of visual acuity, surgically induced astigmatism, complications, and biometric errors.

The ongoing study currently includes 2,022 patients from 16 centers in 10 countries"

http://www.medscape.com/viewarticle/812070
"Anterior Capsule Tears After Laser-Aided Cataract Surgery"

Some surgeons explain the benefits of manual surgery over conventional:

http://www.reviewofophthalmology.com/content/d/cover_focus/i/3110/c/52304/
" Dr. Kershner offers several reasons femtosecond laser technology may not be a major advantage when it comes to fine-tuning cataract surgery for better multifocal outcomes:
• A manual capsulorhexis provides information about the capsule that a laser capsulotomy does not."

http://www.outpatientsurgery.net/surgical-services/cataract-surgery/5-cataract-complications-to-avoid--10-14
"Even in expected routine cases, he'll know something is amiss after he makes the first manual slice of the capsulorhexis — if a femtosecond laser is making the cut, you're not getting the same feel and feedback, says Dr. Melendez."

  
http://www.freedomeyelaser.com.au/laser-vs-manual-cataract-surgery/
"4 Reasons Laser Cataract Surgery Is Not Dr James Genge’s First Choice"

This is from an eye surgeon's blog (one who sometimes posts on this site)  who tends to be concerned about evidence based medicine and what the studies say:

http://eyesurgerysingapore.blogspot.com/2014/11/femtosecond-laser-and-cataract-surgery.html


It is the case that some surgeons disagree on the issue:

http://www.reviewofoptometry.com/content/d/ophthalmic_lenses___and___dispensary/c/50964/
"3. Who Really Needs Femto Laser Cataract Surgery?  
Surgeons disagree on this question, with some advocating routine use of femto, others believing its greater precision is primarily a benefit only to those patients receiving a premium IOL, and still others waiting for more compelling safety and outcomes data to show up in the literature before adopting the technology. "

http://bmctoday.net/crstodayeurope/2014/02/article.asp?f=evaluating-the-impact-of-laser-assisted-capsulotomy
"Evaluating the Impact of Laser-Assisted Capsulotomy : There are two sides to the story. "

http://ophthalmologytimes.modernmedicine.com/ophthalmologytimes/content/tags/barry-seibel-md/laser-refractive-cataract-surgery-benefits-eye-behol?page=full
" Laser refractive cataract surgery: Benefits in eye of beholder
Conventional phaco preferred by some, while transition to LRCS may appeal to others"

[JohnHaganMD]

If you are rolling in money it is worth the extra fees. As said above there is a learning curve and you would ideally like to have a surgeon with a 100 eyes using these techniques. That being said the standard cataract operation using monofocal IOLs is an enormously successful procedure and the incidence of complications is less than 1%. It is also a huge bargain as in most metropolitan areas a cataract/IOL plus 90 days of care costs about half of what dentists charge to put on a crown.

JCH MD

[KayakerNC]

Yeah, you can go cheap, get the monofocals, no astigmatism correction, and hope for the best.
But to increase your odds of having great vision after surgery, you really must look at the options.  And ask yourself, just how much is my vision worth.  Can you put a dollar limit on it?
Since Dr Richardson has decided to not accept Medicare, evidently they won't pay what he thinks he's worth, I no longer value his opinion.
Information on laser?  Try Dr Foster's blog.
http://www.garyfostermd.com/what-is-laser-cataract-surgery/

[SoftwareDeveloper]

One doctor has a good free ebook about all aspects of cataract surgery, including his skepticism of the current utility of laser cataract surgery:

http://david-richardson-md.com/wp-content/uploads/ctb.pdf

Although the book is from 2012, I don't think anything significant has changed, in fact he has a post from this January noting one potential side effect more common in laser cataract surgery, which links to other comments of his on laser cataract surgery:

http://www.about-eyes.com/laser-assisted-cataract-surgery-and-risk-of-macular-swelling/
"Laser Assisted Cataract Surgery and Risk of Macular Swelling"

His skepticism matches the reports I've seen of large scale studies over the  last year or so  indicating that laser cataract surgery so far merely has been shown to have  different complications than non-laser surgery overall (which are rare in both types), and hasn't proven its benefits overall yet for most patients. Many new technologies take time for the initial versions to be polished. That said, the technology is continually improving so it may eventually prove its benefit, and it may be that there merely aren't yet studies on the latest versions which might indicate a benefit.  Most of the large scale studies are of any sort of laser surgery, not studies of a particular model of laser. If you know what laser your surgeon plans to use then you might check for studies specific to that.

There are some special cases I've head there are demonstrated benefits, like with a hard mature cataract (which in the developed world is rarely seen since people usually get surgery before that, except for some rare cases of very rapidly developing cataracts where within a few weeks/months the cataract is mature by the time surgery is done). If there are unusual elements to your case it is possible there is a benefit to it, but I suspect you would have heard from your doctor if there were some uncommon aspects to your case.

I don't know if you are getting astigmatism corrected surgically, I hadn't looked into the current data on how laser correction of that compares to manual surgeries.

I've   heard that  overall the issue is partly that   laser surgery may be  better than an inexperienced surgeon. As with any skill, practice makes perfect and high yearly surgery volumes have been shown to correspond to lower risk of complications. That said, laser surgery itself has a learning curve, depending on the source I think I've seen perhaps the first 100-150 surgeries a surgeon does with a laser they are still learning so its best to be sure the surgeon is past that point. In my case I chose in Dec. 2014 not to go with laser cataract surgery, partly  since the surgeon had done tens of thousands of regular surgeries, but was only perhaps just past the learning curve on a laser.