As I See It

A gentler, safer and, someday, less pricey cataract surgery

The benefits of laser-assisted phaco are obvious, so when will the cost matter less?

By Paul S. Koch, MD, Editor Emeritus

The day I first watched laser-assisted cataract surgery it took almost no time, perhaps three cases, before I whispered to my staff, “When I need cataract surgery, this is how I want to have it done. It’s better this way.” I observed an obvious reduction in trauma to the eye with the laser compared to traditional phaco. It was easy to imagine how we could perform gentler surgery with a lower risk of complications.

Using the laser to prepare the cataract reduces, sometimes to nil, the ultrasound energy we need to break it apart. Cutting back on the jackhammer effect of the ultrasound flattens the turbulence within the eye, making the procedure gentler. On the reduction of ultrasound energy, there is no dispute; it has been shown from the earliest days of laser development.

WHO BENEFITS?

After seeing how much gentler the laser-assisted operation was compared to manual, I identified certain patients whom I felt would clearly benefit from this procedure. Those with high myopia, for example, are at risk for a retinal detachment even years after the operation, presumably as a result of prolonged ultrasound energy within the eye. Reducing that energy by letting the laser divide the cataract first appears to be the place to start, though, because of the prolonged time before that complication strikes, it may be years before we have hard data on this.

Next I would select a patient with a dense cataract because the laser lets us reduce ultrasound energy by as much as half. After that, a patient with guttata, reducing the risk of corneal edema; then one with diabetic retinopathy, to reduce the inflammation that can lead to clinically significant macular edema.

You can see where this is going. Once we can establish the laser-assisted procedure is safer for patients with ocular comorbidities, what about our patients whose eyes are otherwise healthy? Ought they, too, have the option of a gentler and safer operation? And if so, must we become ethically bound to offer only laser-assisted cataract surgery and stop performing manual surgery?

AS COST COMES DOWN

We cannot limit ourselves right now because of the added cost of the laser-assisted procedure. Insurance companies will not cover the added cost of the laser, so we can only perform it when it is part of a refractive operation. That adds out-of-pocket costs for the patient, and for some refractive options that can be pricey. We offer financing plans, but even then it can fall beyond what a patient can afford no matter what we mutually perceive the value of the laser to be.

My prediction: Laser-assisted cataract surgery will be accepted as a more gentle and safe (though never risk-free) operation than traditional cataract surgery. Patients will prefer to have cataract surgery using the laser. As more procedures are performed, the costs will come down, allowing us to charge fees that are affordable for every patient. OM

Paul S. Koch, MD is editor emeritus of Ophthalmology Management and the medical director of Koch Eye Associates in Warwick, RI. His e-mail is paulkoch@kocheye.com.