Laser-assisted cataract surgery: Just because we can, should we?

By Lawrence Piazza, Special to the BDN
Posted Sept. 30, 2012, at 7:20 p.m.

I am writing in response to the recent article in the BDN about laser-assisted cataract surgery (“Bangor eye center among first in nation to offer new cataract surgery,” Sept. 15). New medical technologies often create heightened interest within the community. Both physicians and journalists possess the power to influence public thinking and have an obligation to fully inform their audience and disclose a balanced point of view. Because of the number of questions fielded within my practice regarding this technology, I feel compelled to further explain its use in cataract surgery.

As one of 17 ophthalmologists who care for the patients of Penobscot, Aroostook, Hancock and Washington counties, I am keenly interested in new technologies that improve surgical outcomes for patients. For the past 20 years, I have sought to deploy the most effective technologies that have proven to deliver excellent visual results in patients undergoing refractive cataract surgery. The discussion below reflects the analysis I applied to this new laser technology in deciding whether to adopt this for my patients.

It is critical for patients to comprehend that the laser used in cataract surgery does not vaporize or remove the cataract from the eye. The only difference between modern cataract surgery and laser-assisted cataract surgery is the incisions made prior to performing the actual cataract removal procedure. The surgeon must then physically open those incisions and extract the cataract by traditional means. Although the laser creates these incisions with precision, any skilled surgeon performing modern cataract surgery should be comfortable making these incisions manually with precision diamond blades and forceps. The question remains: Do patients with laser-created incisions see better than those with manually created incisions? So far, the answer is no.

I would like to suggest that patients ask their ophthalmologist and optometrist the following questions when considering laser-assisted compared to modern cataract surgery:

• How safe is laser-assisted cataract surgery? The use of the laser is not without risk as it is dependent on accurate placement of the laser incisions. Additionally, there are reports in the literature whereby the capsule that supports the cataract has ruptured, complicating the removal of the cataract.

• Is laser-assisted cataract surgery effective in providing superior outcomes when compared to traditional nonlaser methods of cataract extraction? A review of the medical literature fails to uncover any peer-reviewed journal articles that show a significant benefit to patients from the use of this laser regarding better or safer visual outcomes as compared with modern surgical methods. When patients see 20-20 or are spectacle-free after cataract surgery, it is not related to the use of this laser. Instead, excellent visual outcomes are based upon surgeon skill, pre-operative measurements, proper intraocular lens selection and subsequent placement, treating any pre-existing corneal astigmatism and successfully removing the cataract without complications. The lens implantation choices that follow, whether by laser-assisted or traditional methods, are identical and include the option of monofocal, multifocal and astigmatic-correcting intraocular lens implants.

• Is laser-assisted cataract surgery more efficient than traditional methods? Although the laser is able to soften the dense cataract, thereby decreasing the energy to remove the cataract, the difference as compared to not using the laser is negligible. This period — less than 1 minute — is offset by a threefold increase in operative time when compared to modern surgery. Extending surgical time is not considered progress and subjects patients to more manipulation of the eye in order to achieve the same post-operative results.

• Is laser-assisted cataract surgery more affordable than traditional methods of cataract removal? The use of the laser in cataract surgery is not covered by Medicare or third-party insurance payers, requiring the patient to incur additional out-of-pocket expenses of $1,200 or more when compared to modern methods of cataract removal. To purchase such a laser, the surgeon will spend nearly $500,000, with annual maintenance fees approaching $50,000. In addition, the laser manufacturers impose a “click” fee that amounts to $400 to $500 per use that gets passed on to the patient. I believe that our role as physicians should include seeking ways to deploy the most cost-effective technologies that provide the best clinical outcomes with proven benefits. This is especially true in this critical time of health care cost containment.

• Why are there so few lasers deployed throughout the country? There are four companies that manufacture femtosecond lasers that create corneal incisions, fashion a circular cut on the lens capsule and soften the cataract. Currently, only 90 devices are deployed throughout the country of nearly 18,000 ophthalmologists. The majority of ophthalmologists nationally are still waiting for results from unbiased clinical studies to prove a clinical advantage of this approach before they adopt this technology. The scarcity of this technology in the ophthalmic community is because most cataract surgeons obtain the same results with traditional modern surgical techniques and cannot justify the added expense of this laser to their patients.

The lure of lasers in cataract surgery is seductive, particularly in the minds of the public. Hence, this technology has the potential to serve as a useful marketing device in any cataract practice. However, lacking proof in improving clinical outcomes, potential complications from its use, a threefold increase in surgical time and the increased expense to our patients are the reasons I have not acquired this technology in my practice to date.

Like the majority of the nation’s eye surgeons, I will continue to monitor the literature for published results of this or any new technology that is proven to enhance clinical outcomes and patient satisfaction. If laser-assisted cataract surgery demonstrates superior visual outcomes over traditional cataract surgery techniques, then I will, of course, make this technology readily available to my patients.

Lawrence Piazza, M.D., is medical director of Coastal Eye Care and Coastal Eye Surgery Center in Ellsworth.

http://bangordailynews.com/2012/09/30/opinion/laser-assisted-cataract-surgery-just-because-we-can-should-we/ printed on September 20, 2014