Eye health

Laser leads to less risky cataract surgery


Understanding laser cataract surgery

When William Hughes, 76, of Miami couldn’t play tennis anymore because his depth perception was off, and couldn’t drive at night due to glare, he and his doctor decided it was time for him to undergo cataract surgery.

Given the choice of manual or laser surgery, he and Dr. Frank Spektor of the Center for Excellence in Eye Care in Miami, opted for the precision of laser technology.

The procedure involves two minuscule cuts being made into the cornea or the clear part at the front of the eye with a femtosecond laser. From here, the doctor has access to the capsule that holds the cloudy lens.

To visualize that capsule, think of an M&M candy, suggests Dr. Richard Kalski of South Miami, who has his own practice and works with Fort Lauderdale Eye Associates. The first candy shell is the front of the capsule in your eye. The doctor uses the laser to cut a precise circle from this layer exposing the chocolate center.

The chocolate represents your cataract. The laser is used to soften and take chunks out of this cloudy lens, which can easily be removed with just suction.

Finally, the foldable acrylic multifocal lens is placed into what looks like a pea shooter, according to Spektor. It’s inserted through the hole in the cornea onto the back shell of the candy or capsule, where it holds itself in place.

The laser can also be used to make precise cuts in the cornea that help reshape the eyeball and correct astigmatism. There are no sutures, no surgical pain and relatively little recovery time as general anesthesia isn’t necessary.

By the day after surgery, Hughes’ vision in his left eye had improved from 20/200 to 20/60. The following day he could read without the glasses he had been wearing for the past 15 years.

But for those who don’t have cataracts but are interested in laser surgery and lens implants, the procedure is called a clear lens extraction and will probably be deemed cosmetic by your insurance company, meaning you have to pay the bill.

Deborah S. Hartz-Seeley

Special to The Miami Herald

Alicia Nash of Miami was tired of wearing glasses. So she went to her doctor and, at age 57, discovered she had the beginning of cataracts.

Although they weren’t yet affecting her sight, she knew both her parents had had cataract surgery in their 70s. And her mother, who is now 85, underwent cataract surgery twice.

Working with Dr. Richard Kalski, who has his own South Miami practice and works with Fort Lauderdale Eye Associates, Nash was told that she had the option to lose the cataracts as well as her glasses.

“The amazing thing about being alive today is that technology lets us achieve things in cataract surgery we wouldn’t have even dreamed about five years ago,” says Dr. Andrew Shatz, medical director at the SightTrust Eye Institute in Sunrise.

Available for only about eight months, femtosecond laser to treat cataracts is not only changing the way the surgery is performed but also the results you can expect after your procedure. The laser is named for the femtosecond, an ultra-short period of time that measures the laser’s optical pulses of light, which are used to cut tissue.

A femtosecond laser was initially used for laser vision correction or Lasik. But that version wasn’t appropriate for cataract surgery.

“It seemed like a very good laser looking for something else to do,” says Dr. William Culbertson, professor of ophthalmology at the University of Miami’s Bascom Palmer Eye Institute.

About seven years ago, he teamed with a colleague in California to develop a laser that could be used for cataract surgery. Their prototype worked well cutting plastic tissue, so they gradually refined it.

Over time, they proved their laser could make very precise microscopic incisions in the capsule and cornea of the eye and soften even the hardest cataracts. They advanced to clinical trials, which led to FDA approval about 1½ years ago.

“This laser makes routine cataract surgery easier, difficult surgery routine and impossible cataract surgery possible,” says Culbertson, quoting a colleague who was involved in the clinical trials.

Depending on the individual, when laser surgery is teamed with premium multifocal lenses, the results can be much better vision. After all, the lenses allow you to see both far and relatively near from the same eye. And astigmatism can be corrected with the choice of either a lens or with laser cuts that reshape the eyeball.

“In the last few years, our focus has been not only to remove the cataract and get rid of the cloudy vision but to make your vision as clear as it can be without glasses, ” Culbertson says.

Cataracts develop when the protein in the lens of the eye becomes cloudy. This might be likened to a newspaper left in the driveway that turns yellow, explains Dr. Frank Spektor of the Center for Excellence in Eye Care in Miami. In the eye, this can be caused by things such as years of sun exposure, smoking, diabetes and obesity.

When our parents and grandparents were diagnosed with the beginnings of cataracts in middle age, their doctors were likely to watch those cataracts for another 10 to 15 years before treating them.

They didn’t want to rush patients into an operation that could have surgical complications. And they wanted to be sure the patient’s vision was affected enough by cataracts that they would see an improvement after the surgery, Shatz says.

When surgery was finally performed, the doctor used a metal or diamond blade to open the eye, remove the cataract with ultrasound and suction, then implant a basic lens that let the patient see either near or far. Glasses were still necessary for either distance or close work.

This manual procedure remains a relatively safe and effective method for treating cataracts, especially when teamed with premium lenses.

But the advantage of laser is that the surgeon can customize each cut for the patient’s eye. Additionally, little or no ultrasound is required for removing the cataract and the procedure is less risky.

“With less energy going into the eye, you tend to get less swelling, so recovery is potentially quicker and our results are more precise and accurate,” Shatz says.

Also, real-time scans of the eye made during surgery allow the doctor to customize each cut.

There are about 200 of these $500,000 machines made by four companies in use throughout the United States. However, there are only about a half-dozen in South Florida and their capabilities differ, depending on the manufacturer and its FDA approvals.

Spektor, who does laser surgery at the Medical Arts Surgery Center at Baptist, likens the size of the laser machine to a Smart car sitting in the operating room. “It even has wheels,” he says.

But unlike a Smart car, laser surgery is relatively expensive. Early cataract surgery may be deemed cosmetic and that can mean it’s not covered by insurance, leading to an out-of-pocket expense of $4,000 to $7,000 per eye.

And even if insurance or Medicare covers some of the costs, it’s usually only for the manual surgery and a basic lens. “The government doesn’t care if we do the surgery with a stick or a laser, it will only pay one amount,” Spektor says.

The use of a laser and a premium lens may add $1,500 to $4,000 in out-of-pocket expenses for each eye.

But some patients don’t mind. Nash, the boomer whose cataracts were in the early stage, can now read a menu, work at her computer and look up a number in the phone book without glasses.

“I don’t need glasses for anything. It means a lot,” she says.

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