Why do they use a laser before the actual cataract surgery?

The use of lasers in cataract/lens implant (IOL) surgery has a long and somewhat bumpy course. The first big breakthrough 35+ years ago was the use of high-frequency ultrasound to break up the hardened lens material of an aged natural lens, what we call a "cataract." Many people called this a "laser" (both patients and doctors) although it was really not, using amplified sound waves, not light. Perhaps "laser" just pushes the right buttons as a meme in a way that "phaco-emulsification" never could.

True lasers are used in LASIK surgery which was introduced in the 1990s, so now at least there were real lasers being promoted and used in eye surgery (although LASIK is not remotely cataract surgery). One such laser, the "femtosecond laser" was introduced during this time to create the corneal flap which is an essential part of LASIK.

A few years ago several companies introduced a new femtosecond laser that did have application in cataract surgery. It could be used to 1) make the entry incision, 2) open the lens capsule, and 3) divide up the natural lens/cataract into chunks. It does not, however, actually emulsify or remove the cataract. That is why, to answer your question finally, your eye surgeon must still manually use the same phaco=emulsification device to finish the job. The IOL is then put inside the same capsular envelope. This is called FLACS (Femtosecond Laser Assisted Cataract Surgery.

Is FLACS better than just using phaco-emulsificiation by itself (plus the IOL of course)? The jury is still out. Most studies to determine its advantages have not shown any significant improvements in visual outcome or optical predictability. Safety issues are actually a little worse with FLACS, but this may be a learning curve issue. The time needed to do the surgery is doubled.

Many detractors of FLACS in the eye community (including eye surgeons) say it is just a marketing ploy. Some point out that FLACS might just be a way to charge patients more for cataract surgery by getting around the price controls of Medicare and Insurance companies. Since the former are an oligopoly, they can (and do) compel cataract surgeons to take what they pay, take it or leave it. Since cataract surgery fees have been ratcheted down to 10% of what they were in 1982 (in inflation adjusted $), being able to offer an upgrade like FLACS is a legal way to get around unreasonably low reimbursements.

My own experience with FLACS is that it offers little, if any, advantages to the patient. I believe we need better lens implants, not necessarily better lasers to use in cataract surgery. My impression is that if you are going to spend extra money on cataract surgery, you would get more value by investing it in "premium" lens implants, such as toric and presbyopia-correcting IOLs.

_Written by J. Trevor Woodhams, M.D. - Chief of Surgery, Woodhams Eye Clinic