In my career, I have learned always to pay attention to the patient’s perspective: what does he or she want? Especially in refractive surgery, it is usually the patients’ preferences that ultimately drive the market and steer what we do surgically. As an example, we surgeons were never able to show that LASIK produced significantly better final results than PRK, but because the healing was quicker and caused less discomfort, patients favored LASIK. I believe the same process will shape laser cataract surgery.
My practice is located in Houston, and we have had the LenSx laser (Alcon Laboratories, Inc., Fort Worth, TX) since February 2010—1 year as I write this article— in a commercial, office-based surgical center. My colleagues and I have studied the science of the technique, refined the hardware and software, and generally learned better how to use the device after several hundred cases. In addition, I have witnessed the patients’ experience with this laser, as the vast majority of them choose it for their surgery and pay more for it.
PATIENTS ACCEPT IT
One of the first things I noticed was how rapidly patients accepted and chose laser cataract surgery. Immediately, I saw that this procedure needed less explanation, education, or counseling than any other new technology we have introduced into our clinic.
We surgeons can all remember the first time we used a new technology with our own patients—our first LASIK procedure, wavefront-guided ablation, presbyopiacorrecting IOL, and so on. All new technologies require a different amount of education for the patient to be able to make an informed choice. Why is laser cataract surgery such an easy concept for them?
SAFETY AND OUTCOMES
Patients want two things from eye surgery: safety and the best possible glasses-free vision as soon as possible. Laser cataract surgery helps to deliver both.
I believe femtosecond lasers offer important advantages over manual cataract surgery in terms of safety. My colleagues and I have shown that using that the laser to prechop the nucleus decreases both phaco time and power, which reduces endothelial cell loss. Comparing my laser cases’ endothelial cell counts to those from a published series after traditional manual cataract procedures, I can show a lower rate of loss with the laser. This could mean better, quicker results and fewer complications.
ADVANTAGES IN DIFFICULT CASES
Femtosecond lasers may have advantages for difficult cases as well, including cases of compromised zonules, traumatic cataracts, and pseudoexfoliation. With the laser, we do not have to stress the zonules when making the capsulorhexis or chopping the nucleus, which could mean fewer dislocated lenses and dropped nuclei. The laser also helps with white cataracts, dislocated lenses, and fibrous capsules. We are better able to optimize the dimensions and construction of the cataract incision and do it time after time with the laser. This may lead to fewer wound leaks, improved lens stability, and lower rates of infection. Better wounds could also actually reduce induced astigmatism, resulting in fewer secondary procedures with their associated risks.
CONTROL AND STANDARDIZATION
In my colleagues and my experience, controlling and standardizing the size and centration of the capsulorhexis with a femtosecond laser increases the accuracy of the spherical component of the IOL. The capsular contraction is more uniform, so the IOL’s effective lens position is less variable. We have also achieved excellent results when using the laser to treat astigmatism at the time of cataract surgery. Thus, laser cataract surgery contributes to a higher rate of glasses-free postoperative vision sooner after surgery. Of course, if the lens is more accurately positioned, fewer IOLs will require exchange, and fewer secondary procedures like LASIK or PRK will be necessary, which increases safety for the patient.
In our clinic, patients are choosing, and paying for, the greater safety and efficacy of laser cataract surgery. I have never seen patients accept a new technology so quickly. Quite simply, patients readily understand the added value of laser cataract surgery.
Stephen G. Slade, MD, is a surgeon at Slade and Baker Vision in Houston. He is the medical director for LenSx Lasers Inc. and chief medical editor of Cataract & Refractive Surgery Today. Dr. Slade may be reached at (713) 626-5544; firstname.lastname@example.org.