Cataract Surgery Renaissance
I have been lucky to be a part of the evolution of cataract surgery along side my accreditation as an Ophthalmologist and during the last three decades of my ophthalmology practice. Starting with ICCE(Intra capsular Cataract Surgery)to ECCE(Extra Capsular Cataract Extraction) with IOL (Intra Ocular Lens) implant along with use of the microscope for the entire procedure, during my post graduation and residency and then phacoemulsification with IOL implant, to begin with – rigid PMMA IOLs to foldable IOLs- hydrophilic, hydrophobic, square edge, Toric to multifocals and EDOFS- I have witnessed it all. Today, with having used FLACS(Femto laser assisted cataract surgery)system, the so called “Laser cataract surgery” along with the gold standard phacoemulsification , side by side for almost a decade, I place on record, the leaps in cataract surgery-
implanting an intraocular lens after cataract removal was the first major revolution in cataract surgery. This was followed by the switch to phacoemusification with a sub 3mm incision and no stitches which raised the bar of cataract surgery rapidly inspite of the steep learning curve for surgeons and a pocket pinch for the patient. With time as the phacoemulsification systems , the intraocular lenses and surgeons skills improved , we reached the quintessence of cataract surgery which now can undoubtedly be called one of the most successful surgery in all of medicine. Today, cataract surgery has evolved into a refractive procedure, in which expectations of spectacle independence are commonplace.
With the turn of the first decade of the new century , we were very excited with the advent of FLACS ( Femto Laser Assisted Cataract Surgery)or “Laser Cataract Surgery” which made tall claims of performing the steps of Phacoemulsification with Laser. Delving into the depths of FLACS, we discovered that FLACS could do only the first three preliminary steps of cataract surgery: 1)making the incision (claimed bladeless)which has to be opened with blades, 2)Capsulorrhesis – making the opening for removing the cataract- we don’t need that as any Eye Surgeon proficient in phacoemulsification has to first master doing a Capsulorrhesis 3)Dividing the cataract into pieces – this too has to be done by the surgeon in the very next step after FLACS where the nucleus needs to be chopped and sucked with the phaco handpiece and the surgeons skill. So FLACS performs only the first 3 preparatory steps with a struggle – has no added benefits to the patient or surgeon over the gold standard phacoemulsification. The laser does not obviate the need for phacoemulsification. Hence ,“ Laser Cataract Surgery” fell far short of our expectations and has really nothing to do with laser.
Setting the record straight-
the transition from ICCE to ECCE- beginning of the “microsurgery “ era and the advent of an intraocular lens (IOL) to replace the cataractous lens –, leading to improved refractive results after surgery was a quantam leap in cataract surgery as surgeons operated with precision under the microscope and patients had spectacle free distant vision which rid them of their high plus power aphakic spectacles
ECCE to phacoemulsification which provides sub 3 mm incision, no stitches, no injections and implantation of a foldable IOl (Monofocal,EDOF Toric )was a lifestyle changing procedure giving excellent visual outcomes, less spectacle dependence and allowing patients to get back to normal life in a span of about a couple of days.
FLACS performs the first 3 preliminary steps with hiccoughs, all of these three steps, a proficient surgeon can perform without a glitch and therefore has no added benefits to the patient or surgeon over the gold standard phacoemulsification! It therefore has a long way to go before we talk of the next leap in cataract surgery!