Cataract surgery may witness the largest technology jump since Dr. Charles Kelman invented phacoemulsification more than 45 years ago. The femtosecond laser used for LASIK surgery has been modified to perform many of the integral steps of cataract surgery. It can fragment the lens, perform an anterior capsulotomy, create all required corneal incisions and create limbal relaxing incisions. And it does it in that order—the exact opposite sequence than traditional scalpel surgery—to ensure accuracy and avoid issues of gas bubble formation.
What does this mean for optometry? It has some specific advantages for our patients: It allows for centered and perfectly formed capsulorhexis, as well as well formed, water tight corneal incisions.1,2
The importance of a well-centered and perfectly formed capsulorhexis is more critical than ever because of the growing use of premium IOLs. With both accommodative and multifocal IOLs––particularly those that are pupil dependent––the performance of the lens can be hampered by an imperfect or decentered capsulorhexis, resulting in glare, halos and night driving problems. The size of the capsulorhexis is also very important in optimizing the performance of accommodating IOLs.
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When comanaging optometrists are screening for postoperative visual complaints in patients who received premium IOLs, a sub-optimal capsulorhexis can be subtle and difficult to detect. If symptoms are severe, a lens exchange could be considered; however, there is significant risk in this procedure.
Well-formed, water tight corneal incisions are also important. Greater stability and reproducibility of corneal incisions may lead to a decrease in rates of endophthalmitis and hypotony. When comanging these patients postoperatively, you may notice very precise incisions.
There are some current limitations and disadvantages of the surgery at this time. The lasers are expensive and require a per usage charge and, currently, Medicare and most insurance companies will not cover the added cost of using this laser.
To make things even more complicated, surgeons who participate in Medicare cannot directly charge patients for the use of this laser during cataract surgery because of the “golden scalpel rule.” The golden scalpel rule basically states that if you can do the same procedure with a less expensive tool, such as a $20 dollar scalpel, you cannot charge any of your patients directly for the use of a more expensive tool like a laser.
But, while cost is currently impeding national adoption, any technology that produces more consistent and safer results eventually gains widespread acceptance.
1. Nagy Z. Comparative Analysis of Laser Assisted and Manual Capsulorhexis During Phacoemulsification. Paper presented at the European Society of Cataract and Refractive Surgeons, September 2010; Paris.
2. Masket S, Sarayba M, Ignacio T, Fram N. Femtosecond laser-assisted cataract incisions: architectural stability and reproducibility. J Cataract Refract Surg. 2010 Jun;36(6):1048-9.