Today, cataract surgery is one of the most commonly performed surgeries in the world. In fact, approximately 10 million1 procedures are performed globally each year.
Cataract surgery in Singapore is extremely safe with a 98%2 success rate. These surgeries enable patients to attain good vision, better than Snellen (internationally-accepted visual requirement for driving) visual acuity of 6/12.
While two decades ago, many cataract surgeries required large incisions and stitches, in recent years, advancements in technology have enabled cataract surgery to be minimally invasive, requiring only a small incision and often no stitches. Minimally invasive cataract surgery, also called phacoemulsification surgery, uses ultrasound energy to break up the cataract into many small pieces which are then suctioned and removed.
About 10 years ago, femtosecond laser-assisted cataract surgery (FLACS) was developed. At that time, I was working at the ophthalmology department at the National University Hospital, and this was the very first local hospital in Singapore to offer FLACS. Hence, I was privileged to be amongst the first surgeons in Singapore to perform this surgery.
Since then, many clinics and surgeons have waxed lyrical about FLACS, claiming that it offers increased accuracy and predictability over conventional cataract surgery, and that it has a higher safety profile than conventional phacoemulsification.
Indeed, is laser surgery truly better than conventional minimally invasive cataract surgery performed with phacoemulsification? Is FLACS suitable for all patients? Let’s find out.
Conventional cataract surgery and FLACS actually share many similarities – for example, both procedures are minimally invasive and usually do not require sutures, and both use ultrasound energy to break up the cataract. The differences between the two procedures are highlighted in red below:
| Conventional phacoemulsification cataract surgery (PCS) | Femtosecond laser-assisted cataract surgery (FLACS) |
|---|---|
| This conventional surgery uses ultrasound energy to liquify the cataract in the eye. 1. An incision is made in the cornea with the use of a blade. 2. The surgeons manually create a 5-6mm opening in the front of the eye lens capsule. 3. A pen-shaped probe is inserted through the cornea opening to ultrasonically break down and suck up the cloudy lens. 4. An artificial intraocular lens (IOL) is implanted, replacing the natural lens and restoring vision. 5. The incision is self-sealing and usually does not require stitches. | This surgery uses a femtosecond laser to create an opening in the front of the eye lens capsule and fragment the cataract. Just like conventional phacoemulsification surgery, ultrasound energy is then still used to liquify the cataract in the eye, 1. Femtosecond laser makes an incision in the cornea. 2. Femtosecond laser makes an opening in the front of the lens capsule. 3. Femtosecond laser is applied to the cataract to break it into smaller pieces. 4. A pen-shaped probe is inserted through the cornea opening to ultrasonically break down and suck up the cloudy lens. 5. An artificial intraocular lens (IOL) is implanted, replacing the natural lens and restoring vision. 6. The incision is self-sealing and usually does not require stitches. *Energy from the laser helps reduce the amount of ultrasound energy needed to break up the lens prior to removal. |
| Factor | Conventional phacoemulsification cataract surgery | Femtosecond laser assisted cataract surgery (FLACS) |
|---|---|---|
| Precision | No convincing clinical evidence3 to support the claim that FLACS is more precise or effective than conventional phacoemulsification surgery. | No convincing clinical evidence3 to support the claim that FLACS is more precise or effective than conventional phacoemulsification surgery. |
| Time | More time is required for FLACS compared to conventional phacoemulsification cataract surgery. This is because after laser application in FLACS, phacoemulsification using ultrasound to break up the lens is still required. | More time is required for FLACS compared to conventional phacoemulsification cataract surgery. This is because after laser application in FLACS, phacoemulsification using ultrasound to break up the lens is still required. |
| Risks | Conventional cataract has a high safety profile. There is a low risk of complications occurring. | In addition to the risks associated with conventional phacoemulsification cataract surgery, FLACS is associated with an additional risk of: - Femtosecond laser-assisted cataract surgery-specific intraoperative capsular complications - Intraoperative miosis |
| Outcome | Studies4 show that conventional phacoemulsification cataract surgery and FLACS have similar outcomes. | Studies4 show that conventional phacoemulsification cataract surgery and FLACS have similar outcomes. |
| Recovery time | The recovery time for both types of surgery is similar. | The recovery time for both types of surgery is similar. |
To summarize, most studies show that the clinical outcomes of FLACS are similar to conventional phacoemulsification cataract surgery. FLACS does help to reduce the amount of ultrasound energy required to break up the lens prior to removal, but for the vast majority of patients, such levels of ultrasound energy are absolutely safe even without FLACS. While FLACS can make cornea incisions to reduce astigmatism, the outcome may not be predictable or long-lasting, hence I prefer toric intraocular lenses to FLACS for astigmatism correction.
Importantly, FLACS is expensive and not cost-effective for the vast majority of patients, who can achieve similarly excellent outcomes from conventional ultrasound cataract surgery alone.
My opinion is that FLACS is an unnecessary and expensive procedure for the vast majority of patients, hence I would usually recommend conventional ultrasound cataract surgery alone. However, in a minority of patients who have a low baseline cornea endothelial cell count (eg. Fuch’s endothelial dystrophy), I would suggest that they consider FLACS to reduce the amount of ultrasound energy required to break up the cataract.
Many patients wrongly believe that they should wait till their cataracts are extremely advanced and their vision becomes exceedingly poor before they should undergo cataract surgery. This belief stems from a time when cataract surgery was performed with large incisions and was associated with poorer outcomes and more complications.
Today, minimally invasive cataract surgery performed with small incisions is associated with excellent outcomes and a high safety profile. Hence, you can choose to undergo cataract surgery once the cataract is affecting your vision and compromising your quality of life. Unnecessarily delaying cataract surgery would not only increase the complexity and risk of the surgery, but is also associated with a higher risk of falls and fractures5.
Ultimately, it is important that you choose a surgeon that you can trust and who can address your concerns. And when it comes to surgeons, here are a few non-negotiables:
To find out more about cataract surgery in Singapore, please read my guide on cataracts, and contact me if you have any questions!
References:
38 Irrawaddy Road Mt Elizabeth Novena Specialist Centre, #06-25, Singapore 329563
Mon - Fri: 9am - 5pm
Saturday: 9am - 1pm
Sunday / PH: Closed
