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What is Bladeless Cataract Surgery?

Cataracts occur when the eye’s natural lens, positioned behind the iris and pupil, turns cloudy. This causes vision impairment, which leads to blindness if left untreated. This eye condition is very common in older people. However, though age is a main contributing factor, it has been observed that certain illnesses and lifestyles can increase one’s risk of developing cataract or worsen the condition.

Much like a camera lens, the eye’s lens is responsible for adjusting focal length, allowing the eye to see objects in various distances clearly. Similar to the cornea, it also helps direct light into the retina to be converted into an image for the brain to interpret.

A cataract forms when proteins and tissues in the lens clump together, preventing light from entering the retina. As a result, vision becomes clouded or blurred. The condition progresses slowly and can grow larger, covering the entire lens. The color of the lens changes as well, from clear to yellowish or brownish.

Surgery remains the best treatment for cataracts. This involves surgically removing the cloudy lens and replacing it with an artificial implant called an intraocular lens (IoL). Cataract treatment can be performed using two surgical methods: conventional or bladeless.

Conventional cataract surgery involves the use of a scalpel blade to manually create incisions on the cornea. The eye surgeon then creates an opening at the front of the lens capsule to access the actual lens. Through this opening, a special probe is inserted to emulsify the lens using high-frequency ultrasound. The broken-down cataract is suctioned out of the eye via a fine tube before the artificial IoL is inserted. The corneal incisions may be closed with stitches, or allowed to heal on their own.

Today, however, a newly developed laser that cleanly and painlessly vaporizes cataracts in a fraction of a second, is set to revolutionize treatments by making cataract treatment bladeless. Though it has the same purpose as conventional surgery (to remove and replace the cloudy lens), bladeless cataract treatment uses femtosecond laser technology instead of a scalpel blade. It first maps the eye in 3D using optical coherence tomography (OCT), allowing the surgeon to customize and perform the procedure with unparalleled accuracy. This method uses much less force and time, resulting in reduced risks of incision burns, lens capsule damage and other complications.


What Happens During a Bladeless Femtosecond Laser Cataract Surgery?

Femtosecond lasers emit optical pulses of extremely short duration (as short as one-quadrillionth of a second) and these ultra-short yet intense bursts of near-infrared light pulses allow tissue to be cut more precisely with negligible heat. This technology has already been used widely in refractive surgery (Lasik) and looks set to revolutionise cataract treatment as well.

During the bladeless cataract surgery, the computer-guided femtosecond laser makes openings in the eye (cornea incisions) that can be programmed to be a precise shape. The femtosecond laser is able to create a perfectly round opening in the front of the lens and break up the lens into pieces. The dissolved cataract is subsequently removed with phacoemulsification. All this is done with an image-guidance system that provides real-time 3D and high-resolution images of the eye.


Correcting Vision

During cataract surgery, new and different types of IoLs can also now be inserted to correct the various types of refractive errors. This new approach is more aptly called cataract refractive surgery.

The most common type of IoL is placed behind the iris within the lens capsule (the elastic bag where the natural lens used to be). The IoL acts just like the natural lens to focus light onto the back of the eye (the light-sensitive retina). Conventionally, monofocal IoLs provide a single set focal point, usually for distance vision. This means cataract surgery patients, while being able to see clearly within a long distance, will still require corrective spectacles for near and intermediate ranges. Alternatively, the cataract surgeon may choose to insert an IoL in one eye for near vision and an IoL in the other eye for distance vision. This technique requires adaptation, since each eye will then be oriented towards different needs.

Multifocal IoLs, or advanced technology IoLs, are a newer type of lens that treats multiple focal points and reduces or eliminates the need for eyeglasses or contact lenses after cataract surgery. This is possible through highly specialised optics that divide light and focus it on more than one point to provide a range from near to far eyesight. Some IoLs can also correct astigmatism and minimise the need for distance vision glasses after surgery. Though near and intermediate vision with multifocal IoLs were found to be satisfactory, intermediate vision was not as clear.

Trifocal IoLs, on the other hand, are designed to deliver visual clarity in near, intermediate and far distances with minimal glare and halos at night. With this implant, the patient will be able to switch back and forth between objects at varying lengths without the need for corrective spectacles.

No single lens works best for everyone. The eye cataract surgeon will determine the most appropriate option for the patient. With appropriate IoL selection, high-precision bladeless cataract refractive surgery has become a reality!


A Multitude of Benefits

Apart from being more precise and predictable, these new lasers also mean better patient outcomes. The circular opening created by the femtosecond laser are more architecturally round and perfectly centred; studies have shown that this is very important in keeping the IoL well-positioned and stable. The surgical outcomes are also more predictable.

Moreover, the laser reduces the amount of ultrasound energy used during phacoemulsification, reducing risk of complications and injury. The image-guidance system also increases accuracy and allows customisation. While most people are suitable for bladeless cataract surgery, those who are not include those with cornea disease, glaucoma or eyes which cannot tolerate or cooperate with the suction system to stabilise the eye before the laser.