A cataract is a condition that every one of us will get. This is especially true in a country like Singapore where life expectancy is so long! Chances are, the day will come when our elderly parents, or even us ourselves, will require a cataract surgery done. But when that time comes, do we go for bladeless? Or manual cataract surgery?

I’m going to give my personal view on this situation based on my experience as an eye specialist.

How Cataract Surgery Is Performed

Before we delve into one of the greatest debates concerning cataract surgery, let us understand the key steps of modern-day cataract surgery.

Doctor Claudine Pang Cataract

STEP 1: approximately 2mm incision is made with a blade at the edge of the cornea for the insertion of the microscopic instruments

STEP 2: the creation of a circular opening at the top of the cataract lens bag. This is akin to opening the lid of a can with a can-opener. It is preferential for this opening to adopt a close to perfect circular shape in order for the bag to hold the intraocular lens well. I say ‘close to perfect’ because this step is performed using forceps by hand so this circle can never be truly geometrically circular.

STEP 3: cracking and breaking up of the cataract within the bag and the suction of the pieces into the vacuum-like probe.

STEP 4: insertion of the intraocular lens into the bag.

With the advent of ‘bladeless’ cataract surgery, the first 3 steps that I mentioned earlier can be assisted by a femtosecond laser machine.

To explain, firstly the corneal incision is made not with the blade, but with the femtosecond laser. The plus point is that the wound can be made with greater precision. The downside is that sometimes the laser isn’t able to make a through and through a cut, so the half-created wound requires a blade to finish the job, which could get messed up if the blade doesn’t follow the initial laser cut.

Secondly, the can-opener step can also be made with the femtosecond laser. The plus point here is that the opening can now be made perfectly circular which was not possible when done manually. This is helpful in complex cataract cases where creating the opening with hand requires a considerably higher level of skill. The opening can also be centred well which is especially important when implanting multifocal intraocular lenses. On the flip side, if the laser makes an incomplete opening, we’re left with a perforated opening that requires manual manipulation which could get a little tricky.

Thirdly, the femtosecond laser can help to soften a hard cataract and make it easier to be removed. The only downside of this is that the laser energy may alter the lens proteins and lead to increased eye inflammation.

With its pros and cons, the great debate continues. After all, is said and done, the penultimate question is – does bladeless cataract surgery provide better visual outcomes or lower complication rates?

PROSCONS
STEP 1 – IncisionBetter precisionMight not cut cleanly
STEP 2 – Creating a holeA perfectly circular hole in the centreTrickier if the opening was incomplete
STEP 3 – Break cataractCan soften hard cataractsMight increase eye inflammation

*Summary of pros & cons of bladeless cataract surgery

So Is Bladeless Cataract Surgery Safer?

Many, MANY large studies have been performed to address this important question.

Surprisingly, the verdict is that visual outcomes and complication rates are no different between both methods, and no single study has been able to prove the superiority of one method over the other. Our belief at Asia Retina is that bladeless cataract surgery does not have better visual outcomes when compared to the manual method and does not lead to lower complication rates either.

Maybe Even… Downsides?

Have I mentioned that bladeless surgery often takes a long time to perform? This is because patients need to have the laser done in a separate room before moving to the operating room for the actual surgery.

Moreover, the cost of the bladeless surgery to the patient is much higher due to the added cost of the femtosecond laser. Higher cost for the same visual outcome and same complication rate, the benefits may be difficult to appreciate.

femtosecond laser

*This is where your money goes

Here’s an analogy to consider: we were perfectly fine driving our cars, getting from one place to another. Now we want to bring in the robotic or fully-automated vehicles that drive us to our destination. It’s way more expensive, needless to say. Does it really improve the end result? What happens when robotics or automation fails us? With the lack of practice and the over-reliance on artificial intelligence, would we still know how to drive ourselves back?

It could be argued that femtosecond laser has its benefits especially in the hands of a weaker surgeon because it no longer relies on the surgeon’s inherent skill.

Something to think about for F1 fans: if you had Kimi Raikkonen (one of the top race car drivers in the world) sitting in your driver’s seat, would you switch on the fully-automated button? Ok, I am a Kimi Raikkonen fan, I admit, you may wish to imagine it was Lewis Hamilton instead.

Since both methods have their pros and cons, the key is to identify which patient would benefit from which method. So, the answer to whether bladeless surgery is really better will differ from surgeon to surgeon and patient to patient, depending on the complexity of the cataract in question.

The bottom line is – Do not fall for the gimmick that the femtosecond laser is always better. More expensive is NOT always better!

Do note that neither am I saying the femtosecond laser is bad. 

But every piece of equipment has a use, depending on each individual patient’s case and the surgeon’s skill. The cost of cataract surgery can be quite expensive, so get an experienced eye specialist to advise you before simply picking the most expensive option!

References:

1. Bobrow JC, Blecher MH, Glasser DB, et al. Surgery for Cataract. Lens and Cataract. 2010-2011. Singapore: American Academy of Ophthalmology; 2010. Section 11: Chap 8.

2. Chee SP, Chan NS, Yang Y, Ti SE. Femtosecond laser-assisted cataract surgery for the white cataract. Br J Ophthalmol. 2018 Jun 15.

3. Yanoff M, Duker JS, eds. Small Incision and Femtosecond Laser Cataract Surgery. Ophthalmology. 4th ed. Elsevier; 2014. 371-77.

4. Alio JL, Fine IH. Minimizing Incisions and Maximizing Outcomes in Cataract Surgery. Germany: Springer; 2010.

5. Kohnen T, Koch DD. Cataract and Refractive Surgery (Essentials in Ophthalmology). Germany: Springer; 2005.

6. Seibel BS. Phacodynamics Mastering the Tools and Techniques of Phacoemulsification Surgery. 2nd Ed. 1995.