By Mark Siegel

The use of the Femtosecond Laser in assisting with phacoemulsification for cataract surgery represents what may be a new technological approach yielding even more predictable and refined results in what is already a remarkably safe and effective cataract operation. The Femtosecond Laser has been successfully used for a number of years in laser eye surgery for the laser vision correction of common vision disorders such as nearsightedness, farsightedness and astigmatism. This laser technology has been used as an alternative to manual and mechanical methods of creating a reproducible and precise thin layer of tissue under which another laser places the optical correction.<!--more-->
Cataract removal entails removing the cloudy natural crystalline lens of the eye using a technique that is called phacoemulsification. Phacoemulsification uses ultrasonic energy to liquefy the lens material so that it may be aspirated. Phacoemulsification requires many manual steps and considerable skills of the cataract surgeon. The potential advantage of Femtosecond Laser Assisted Cataract Surgery (FLAC) is that it allows the consolidation and conversion of the many skill intensive steps of cataract removal into a more predictable procedure that benefits from enhanced laser created surgeon controlled precision.
From a surgical perspective, some cataract surgeons believe that incorporating the Femtosecond Laser into cataract surgery will be useful for:
• Creating “perfect” incisions in terms of size and architecture, which is important in order to have the incision seal properly without the use of stitches and to prevent infection. (not yet shown by any studies)
• Creating a perfectly centered and sized “capsulotomy”, which is the “opening” prepared in the front of the crystalline lens through which the cloudy lens material is removed (the only aspect  in studies to be superior but did not translate into better post-operative vision)
• Liquefying, softening or “chopping” the crystalline lens, in order to allow the cloudy material to be phacoemulsified (still requires manual phaco after)
• Creating the possibility of precise corneal incisions, such as might be performed with limbal relaxing incisions (LRI) to correct pre-existing  astigmatism (better corrected with Toric intraocular lenses in studies)
There are currently three companies that have received FDA approval to use their Femtosecond lasers for creating the corneal incisions, corneal relaxing incisions, capsulotomies and lens fragmentation. It is very important to understand that so far the only statistically significant benefit is that the laser makes more precise capsulotomies than manual capsulotomies. There is no evidence that this translates into better post-operative vision. Consequently, Medicare or private insurance will not pay for the use of this laser. Patients may still choose to have laser assisted   cataract surgery performed, but they will have to pay completely out of pocket and cannot bill their insurance company
Am I excited about this technology — YES! However, it is important to resist the hype and wait until studies actually show better post-operative results than manual cataract surgery.

<em>Board certified, American Board of Ophthalmology, www.seaislandophthalmology.com</em>