Lasers have played an important role in ophthalmic care for many years. Patients have been aware of their use and have often, therefore, quite naturally assumed that cataract surgery has been carried out using a laser. This has NOT been the case...... until now.
The surgeons at Manchester Eye Surgery Ltd have been instrumental in bringing Laser cataract surgery to the UK. In 2012 there were only 2 centres in the UK able to offer this revolutionary surgical technique to their patients, one of these being our centre here in Manchester.
Patients have assumed, and wanted, lasers to be involved in cataract surgery because they are already aware of the ultra-precision with which lasers are able to carry out their tasks. We are all aware of the role, for example, of excimer lasers in Laser Vision Correction procedures such as LASIK.
However, Laser Cataract surgery and Laser Clear Lens surgery have only now become a reality, offering our patients a procedure which is even safer, more precise and with greater predictability. The use of lasers eliminates the role of the surgeon in several very delicate parts of the surgical procedure, thus reducing the chance of human error in performing those tasks.
When our grandparents had cataract surgery, it was a procedure which was often delayed until they were nearly blind and there was no choice other than undergoing surgery. With advancements in surgical approach and technology available to us, the nature of this surgery is vastly different. Cataract surgery is now a refractive surgical procedure and is able to offer far better refractive and visual outcomes, with significantly less risk, than was ever the case in the past. As such we are able to offer this surgery to our patients, as soon as they have sufficient symptoms related to cataract which are hampering their lifestyle. Why wait until you have to stop driving before you have your surgery?
For the last 20 years, we have been able to offer our patients cataract surgery with a small ultrasonic probe (phacoemulsification surgery) and this has been the best technique for both cataract and clear lens surgery. However, this surgical technique requires the use of blades, needle tips and sharp forceps for several crucial and delicate parts of the procedure. The advent of our new Femtosecond laser technology means that these important parts of the procedure can be carried out by the Femtosecond cataract laser, finally making the procedure Bladeless.
LASER CLEAR LENS / PRELEX SURGERY
There are 2 very delicate steps which need to be carried out before the ultrasonic probe (phacoemulsification probe), which has formed the basis of most cataract , or clear lens surgery, for the last 20 years, can be used.
These steps are:
- Corneal incision
- Opening of anterior lens capsule or Capsulorrhexis (CCC)
The Femtosecond laser is now able to offer us a way of carrying these steps out in a way which is safer, more precise and more predictable than ever before. In addition, the laser is able to perform other procedures including Lens fragmentation (breaking up the lens) and Arcuate corneal incisions (to alter the shape of the cornea).
Traditionally created by the surgeon using a blade, this step is important in creating a precise opening through which instruments can be placed in the eye, to deal with the lens. If the incision has a watertight seal around the instruments, the eye remains stable through the surgery which can then be carried out more safely and quicker.
The Femtosecond laser offers:
- Bladeless surgery
- Precise incision construction and better watertight seal
- Self-sealing incision at the end of surgery with less chance of wound leak or post-op infection
- Suture free surgery and no suture-related astigmatism
The Femtosecond laser is able to create a precise circular capsulorrhexis (anterior lens capsule opening) of the exact size and shape, in the correct position, almost every single time.
This step has become much more predictable and safer than was ever possible before, with previous manual techniques, and is particularly important when premium lens implants are being used.
The Femtosecond laser offers:
- Precise circular capsulorrhexis with predictable overlap of the lens implant edges and less chance of lens implant tilt
- Precise size capsulorrhexis construction making removal of the cataract easier
- Precise shape and size of capsulorrhexis resulting in better lens implant centration
- Less chance of capsulorrhexis edge tear and possible other complications
Where there is moderate pre-existing astigmatism, the shape of the cornea can be modified to compensate for this. One such technique is known as Arcuate Keratotomies, or Corneal relaxing incisions. In the past, these have been carried out using a blade.
The Femtosecond laser offers:
- Bladeless surgery
- Precise placement, size, shape and depth of arcuate incisions
- Reduction in astigmatism
- Better visual outcomes
Lens / cataract fragmentation
Cataract and clear lens surgery have been carried out through a small incision (typically less than 3mm) for many years. This means that the clear lens needs to be broken up into tiny pieces or fragments, so that it can be removed from the eye. This step was previously carried out by the phacoemulsification probe, often requiring quite a lot of ultrasound energy.
The Femtosecond laser offers:
- Precise fragmentation of the clear lens
- Less stress on the lens zonules (delicate fibrils which support the lens bag)
- Reduction in ultrasound power within the eye and thereby less risk of consequential damage to the cornea
What does the surgery involve?
On the day of surgery and once in the clinic your pupil will be dilated with either drops or a small pledget placed just inside the lower eyelid. The area around your eye will be washed and cleansed. The operation usually takes about 20 minutes and is painless as it is performed under a local or topical anaesthetic.
Use of the brand new Femtosecond Laser technology allows a “bladeless” approach to the procedure. The laser is used to make the corneal incisions, open the front part of the membrane surrounding the cataract (CCC), to break-up or fragment the cataract and also to make relaxing incisions in the cornea, if required.
Traditionally, the technology used in cataract surgery is a machine called a phacoemulsifier (phaco). This phaco probe is still used as it emits ultrasound waves that further soften and break up the cloudy lens, allowing it’s removal by suction. Once removed, the original cataractous lens is replaced by a lens implant which is folded and inserted through the tiny incision, where it unfolds once in place in the eye and where it can remain even better centred and stable, than was previously the case, because of the Laser created CCC. There are usually no stitches required, and you can return home the same day and look forward to a rapid and pain-free recovery.
Can everyone have Laser cataract surgery?
Whilst there are a few exceptions, the majority of patients can have surgery using the Femtosecond laser. The exceptions include those patients with poorly dilating pupils or with significant corneal scarring. For these patients, other advanced surgical techniques are available.
Are surgical blades used?
This surgery uses the Femtosecond laser to make all necessary incisions and is, as such, bladeless.
Laser Cataract Surgery is a New Technique, What About the Risks?
Laser Cataract Surgery is indeed a new innovation, but the underlying Femtosecond laser technology has a proven track record in ophthalmic surgery and has been used to create LASIK flaps for 10 years. All forms of surgery have associated risks, but Femtosecond laser cataract surgery actually makes the procedure more precise, reproducible, predictable and safer than before.
Is Laser cataract surgery more expensive?
This surgery uses the latest in Femtosecond laser technology. This extremely sophisticated technology has developed following years of research and as such there is a moderate increase in the cost of the surgery.
Will my Private Medical Insurance Company pay for this procedure?
The costs associated with cataract surgery are covered by most insurance companies. At present, however, insurance companies do not cover the extra costs associated with Femtosecond laser techniques and an additional payment from the patient will therefore be necessary.
How long will the surgery take?
The operation itself will take up to 20-30 minutes depending upon the complexity of the case. However you will need to plan to be in the clinic/hospital for upto 3 hours. You will need someone to collect you, or transport can be arranged for you, in advance.
What happens after the operation?
After the operation you will rest for a while and have refreshments. You will be given a dressing pack to clean the eye the following day, and some antibiotic and anti-inflammatory eye drops to apply at home after the surgery, for 2-4 weeks.
How quickly will my vision be restored?
Your vision will be slightly blurred for a few days while your eye heals. It is usual to feel some discomfort until your eye settles but there should be no pain. Any discomfort can be eased by taking paracetamol. After a couple of days you will start to notice a significant improvement in your vision. You will see the surgeon again after 5-10 days and may visit your optometrist for new glasses after 4-6 weeks (unless you are due to have second eye surgery). You can quickly return to many everyday activities, although heavy lifting or other strenuous activities should be avoided for at least 2 weeks. The healing eye needs time to adjust so that it can focus properly with the other eye, especially if the other eye has a cataract. Ask your surgeon or optometrist when you can resume driving.
What will my vision be like after my eye has healed?
Once you have been given your new glasses, you may notice that everything seems a lot brighter than you remember. Colours may be sharper and may have a blue-ish tinge. Or, in bright sunlight, you may feel you are looking through rose-coloured glasses. These colour tinges are normal and are because you are now looking at the world through a clear lens that is no longer cloudy. Within a few months your brain will get used to your new clear vision and these colours should go away.
Can I have both eyes done at once?
If you have cataracts in both eyes, the surgeon will not usually remove them both at the same time. You will need to have each done separately, although they can both generally be done within anything from 1-6 weeks of each other.
What are some of the risks of cataract surgery?
Your Consultant has performed thousands of cataract operations. Manchester Eye Surgery Ltd ensure that the technology and products used for the surgery are of the highest standards available. Although the vast majority of patients achieve excellent results without complications, it should not be forgotten that cataract removal is a surgical procedure. As with all forms of eye surgery, cataract removal has risks and whilst we make every effort to minimise them, they cannot be totally eliminated. The most common and potentially serious risks associated with the cataract operation are:
- Retinal Detachment – occurs when the retina detaches from its normal position and can result in severe loss of vision if surgical correction is not successful. The approximate risk of a retinal detachment in the general population is 0.01% per year. Someone who is hyperopic may have a smaller risk than this, whereas a myopic patient has a slightly higher risk than this.
- Infection – every time there is an incision made in an eye for any reason it is possible to get an infection inside the eye which has the potential to cause severe visual loss. This problem is very rare and our rate of endophthalmitis is less than 0.1%. After the cataract operation, to help protect against infection, eye-drops are prescribed which must be used as directed.
- Bleeding – there is a small risk of a serious peri-operative bleed either in the orbit, or within the eye itself.
- Macular Oedema – is an accumulation of fluid at the central retina which can cause temporary or permanent reduction in vision after surgery. The postoperative eye-drops help to reduce this risk.
- Floaters – are often noticeable immediately after surgery but usually become less noticeable with time.
- Posterior Capsule Opacification (PCO) – is thickening of the residual lens membrane which supports the lens implant. Approximately 25-30% of patients will, at some stage, notice a reduction in their vision due to PCO. It may occur months or even years after surgery and is easily and quickly dealt with by outpatient laser treatment.
- Specialised multifocal lens implants (e.g. toric, accommodative, multifocal, or toric multifocal) may present other risks/side effects which your surgeon will discuss with you
- Other possible complications include tearing of the lens capsule (<1%) which could mean that it is more difficult to implant an intraocular lens. There are other extremely rare complications which your surgeon can discuss with you prior to surgery.
Use of the Femtosecond laser allows for more precise, reproducible, predictable and therefore safer surgery. However, there are still risks involved with all types of surgery, including Laser Cataract Surgery.
How long does the implant last?
The lens implants used are generally left in place for life.
Can a cataract come back?
Once you have a replacement lens implant (intra-ocular lens or IOL as it is commonly called) you cannot develop another cataract in that eye. However, it is quite common for the membrane that holds the lens in place to develop some cell re-growth in the first 12-36 months after surgery. Should this occur, it is easily and painlessly removed in seconds using a small laser beam in the surgeons consulting rooms. This technique is called YAG laser capsulotomy and is a relatively simple outpatient procedure.
What if I don’t want to have an operation for my cataract?
Cataracts develop usually with age. The process is a progressive one and cataracts do not go away of their own accord. If you have cataract and it is causing you significant symptoms, or you are concerned it may interfere with your ability to drive, then the only realistic, long-term solution is cataract surgery. For some people, changing spectacle prescription may be beneficial as a short-term measure. However, it is not unusual for several spectacle changes to be necessary over a short period of time. This is both expensive and frustrating. There is no other effective treatment, for cataract, apart from surgery in the hands of a specialist ophthalmic surgeon.