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Cataract Surgeon: What constitutes a "good surgeon"

In many posts, I have seen it suggested that one obtain the services of "a good eye surgeon" for their cataract surgery.  Please tell me what constitutes a "good eye surgeon?"  Also, is it worth the extra expense to have laser cataract surgery?   I need cataract surgery in the very near future and feel as though I am attempting to make a life-altering decision without all the facts!  Any input is greatly appreciated.
8 Responses
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Castle Connolly provides a list of peer nominated Top Doctors in multiple fields of medicine.  You can search by specialty and zip code
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Its the most common, and very safe, surgery out there so the odds are whoever you choose will leave you with good results. However there are of course rare complications, so it does make sense to choose the best doctor you can just to play it safe.

Often people try to ask local optometrists for their opinions since they may see patients who have been to various surgeons for followups so they may have the best sense of the results. Sometimes of course they may get co-management fees that vary by surgeon, hopefully if you've had a long time optometrist they won't let that bias them, and you can try asking more than one.

You don't say where you live (there are posters around the world, even though most are in the US) for anyone to suggest specifics. One way to attempt to find a good doctor is of course to find out what other doctors think of them. There are some groups that collect data from doctors in an area about who they would use if they or their family needed treatment. Some cities like Denver have magazines that publish the best doctors from such surveys (or it may be newspapers or TV stations I guess elsewhere), I don't know what city you are in. There is a national site BestDoctors.com which seems to unfortunately only provide the result of their surveys to people whose insurers pay for access. I did see a Denver magazine publish the listing from that site for Denver one year, I don't know if its common for local publications to pay for it.

Of course what matters most is the actual doctor rather than just the facility, but US News and World Report publishes a list of what they rate as the top eye hospitals:

There is an International Intraocular Implant club which only has about 300 members since they are chosen by the existing members:

Membership would indicate respect by their peers, though it could be for clinical judgement rather than surgical technique, but since it is a simple surgery I'd lean towards judgment being important to handle whatever rare complications might arise.

  One thing you can try asking for are statistics on their results (e.g. complication rates, how close they come to hitting the refraction target, etc). They may not have those (though ideally they should be tracking such things to be trying to figure out how to improve their results). You want a high volume surgeon who has done many operations since as with any skill practice helps, especially since some complications are rare and it increases the odds they've learned how to deal with them (as to what high volume is, the issue is to compare among your options, mine had done 40,000+ surgeries, which isn't common). Ideally you want someone who is still doing lots of operations to keep their skills up (vs. say if a doctor is mostly managing the clinic and his surgeries were mostly in the past). Even an experienced manual surgeon has a learning curve with laser surgery, it sounds like 100-150 or so laser surgeries should get past that (though some studies use 50 as a cutoff).

There are two aspects of a good surgeon: good clinical judgement and good surgical technique. If the surgeon is on faculty at a medical school, or involved in say professional organizations that set care standards, that would be another clue that their peers respect their judgement.

One thing I did when seeking a surgeon abroad (to get a newer IOL not yet approved here) was to search publications targeted at cataract surgeons, and conferences, to see surgeons who were asked for quotes for articles and to give talks at conferences. That seemed at least one clue they were respected for their peers for clinical judgement, but of course says nothing about their physical surgical skill. I don't know how much screening goes on to select surgeons to do clinical trials involving surgery. However I did consider it a good sign if a surgeon was involved in IOL trials since I figured the lens companies (or the doctor organizing the trials) wouldn't want the results tainted by poor surgical technique.
Avatar universal
The pros/cons of laser cataract surgery are still being debated among surgeons since the data is mixed over whether or not it is better for the typical patient, or merely different. (some new technologies are merely "cool", or in this case I think merely will take time to be polished to show a demonstrable benefit). For most patients either way is very safe and yields good results, so it takes large studies to try to isolate small differences between the two methods, but unfortunately some surgeons just rely on their subjective intuition rather than the data to side one way or another. The studies tend to show lower rates of some complications and higher rates of others (though most complications are minor and can be worked around and don't effect outcome).

You need to determine if you have any other eye health issues or risk factors for complications that may tip the balance to go one way or another. For instance I heard from someone with a mature cataract who has discovered there seems to be good evidence and rationale for using the laser in that case. In my simple case I chose not to use the laser even though my surgeon offered it since he acknowledged it likely wouldn't make a difference (he thought the main benefit was providing good results for less experienced surgeons), and I had seen articles suggesting that there is some benefit for manual surgeons to get a "feel" for the lens capsule.  

This free ebook for cataract patients by a surgeon who is skeptical of the benefits of laser cataract surgery is a good place to start and provides perspective (although its a couple of years old or so, my impression is that the views of the industry haven't  changed yet):


This is an overview by someone more biased in favor of cataract surgery,

but you'll note that some of the comments are speculative about its benefits. e.g. suggesting that it "should also result in less chance of capsule breakage." That suggests it was written prior to studies that suggest the opposite (though the technology may improve to change that).

Recent studies:

" Large prospective comparative cohort series found little difference in safety or visual outcomes between femtosecond (FS) laser-assisted cataract surgery and standard phaco surgery, Brendan J Vote MD, Tasmanian Eye Institute, Launceston, Tasmania, Australia, told the XXXII Congress of the ESCRS in London.

The study examined 4,080 consecutive cases operated by five surgeons at a single regional day surgery centre from May 2012 through to November 2013, Dr Vote reported.

“The visual benefits of laser cataract surgery have yet to be clearly established. As all of us are aware, cost effectiveness or the lack thereof for laser cataract surgery remains a significant obstacle to the uptake of this technology,” Dr Vote said."

The actual study journal article that article mentioned:


And this is from a different large study late last year showing similar mixed results (e.g. a slightly higher complication rate with laser surgery.. but *what* the complications are is part of what matters).


Preliminary results of the ESCRS/EUREQUO Femtosecond Laser-Assisted Cataract Surgery (FLACS) study showed that laser-assisted cataract surgery (LACS) is as good as routine phacoemulsification, but currently does not outperform it, Peter Barry, FRCS, said during the XXXII Congress of the ESCRS meeting in London.1

The FLACS study, funded entirely by the ESCRS without the participation of industry, represents the first time that the outcomes of LACS have been compared with the outcomes in matched patients undergoing routine phacoemulsification in terms of visual acuity, surgically induced astigmatism, complications, and biometric errors.

The ongoing study currently includes 2,022 patients from 16 centers in 10 countries who underwent LACS between December 2013 and August 2014 and 4,962 patients randomly selected from a pragmatic sampling of 100,000 patients enrolled in the EUREQUO study, a database that includes approximately 1.5 million patients who have undergone cataract surgery. To facilitate honest reporting, individual surgeons, clinics, and patients participating in the FLACS study are anonymous in the database, Dr. Barry said. Additionally, all surgeons had previously completed 50 LACS procedures in order to avoid bias from a learning curve."

" Femtosecond Cataract: What the Data Says
A review of how femtosecond-assisted cataract surgery is faring in the literature.
“I think most surgeons would recognize that femtosecond laser cataract surgery is brilliant—as long as they didn’t have to pay for it,” jokes Hyderabad, India, surgeon Kasu Prasad Reddy. Though Dr. Reddy uses the femtosecond in his practice, he acknowledges that his fellow surgeons have to think long and hard about investing hundreds of thousands of dollars in a device when they already get excellent results from conventional phacoemulsification. This thinking logically leads them to wonder what data exists on femtosecond that might shed some light on the kind of results they could expect with the new procedure. To help surgeons answer this question, following is a review of the major femtosecond research from the past several years, as well as thoughts from researchers on their findings."
Avatar universal
Continued on laser cataract surgery, here are clips related to the issue of manual surgery giving more of a "feel" for the eye (these were part of what tipped me towards going for the blade without enough evidence to suggest the laser would be of use in my case):

"Dr. Kershner offers several reasons femtosecond laser technology may not be a major advantage when it comes to fine-tuning cataract surgery for better multifocal outcomes:
• A manual capsulorhexis provides information about the capsule that a laser capsulotomy does not. “Back in 1994 I developed the first capsulorhexis cystotome forceps,” says Dr. Kershner. “That simplified the capsular tear by letting the surgeon open the capsule and create the tear with a single instrument through a 1-mm incision. The added benefit of never letting go of the anterior capsular flap was to give the surgeon the opportunity to assess the capsule. We used to call it ‘reading the capsule.’ ...
  When you’re manually tearing the anterior capsule you can feel the nature of it. Is it elastic or brittle? Does it tear rapidly or slowly? This gives you insight into the nature of the posterior capsule. Thus, if you get an inadvertent posterior capsule rupture at the beginning of a case, you will have seen it coming because you had the ability to read the capsule. With femto technology, the surgeon is separated from his surgical field.”

"Robert F. Melendez, MD, a cataract and refractive surgeon at Eye Associates of New Mexico in Albuquerque, says history of eye disease or past trauma are red flags of a loose capsular bag. Even in expected routine cases, he'll know something is amiss after he makes the first manual slice of the capsulorhexis — if a femtosecond laser is making the cut, you're not getting the same feel and feedback, says Dr. Melendez.

When the bag feels loose, he makes the incision slightly larger — approximately 6.25 mm instead of his standard 5.75 mm — to relieve stress on the zonules. He considers the larger capsulorhexis a safety measure that lets him prolapse the lens into the anterior chamber if necessary."

This is from an eye surgeon's blog, one who tends to be concerned about evidence based medicine and what the studies say:


Entry on a surgeon's blog
"4 Reasons Laser Cataract Surgery Is Not Dr James Genge’s First Choice

        Cataract laser surgery carries a 10x increased risk of anterior capsule tears that can compromise the outcome.
        Cataract laser surgery carries an increased risk of macular/retinal swelling.
        Inaccurate incision placement is more common with lasers than a manual approach."

Though some issues need to be kept in perspective, e.g. capsular tears are still rare so that 10x increase isn't quite as major as it appears at first glance (even if it is an issue), and small tears aren't a problem, and even large tears merely mean a different lens must be implanted outside the bag.

"Anterior Capsule Tears After Laser-Aided Cataract Surgery"

The literature has a number of articles where surgeons debate both sides like these:
"Evaluating the Impact of Laser-Assisted Capsulotomy : There are two sides to the story. "

" Laser refractive cataract surgery: Benefits in eye of beholder
Conventional phaco preferred by some, while transition to LRCS may appeal to others"

Avatar universal
This is a few minute video from this month, interviewing a surgeon who gave a talk at the yearly ASCRS conference about:

"The Ethics of Femtosecond Laser Cataract Surgery"

And discussing the issue  for instance of   being careful for instance to distinguish between the differing personal beliefs of surgeons, vs. what the evidence shows. The wording difference can be subtle, and patients are often not going to be paying close enough attention to realize the distinction they are trying to make.

As this mentions explicitly:

"3. Who Really Needs Femto Laser Cataract Surgery?  
Surgeons disagree on this question, with some advocating routine use of femto, others believing its greater precision is primarily a benefit only to those patients receiving a premium IOL, and still others waiting for more compelling safety and outcomes data to show up in the literature before adopting the technology."
Avatar universal
If anyone has Lasik Surgery, especially when younger, it is my understanding that you need to obtain and retain all your presurgery and postsurgery measurements.
Later on in life if you do need cataract surgery, these measurements will be very helpful.
Avatar universal
A new article on laser cataract surgery (FLACS=Femotsecond Laser Assisted Cataract Surgery) mentions that the technology is still a work in progress with tradeoffs, and not as fully developed as it will be eventually:

"However, the reduction in ultrasound input has to be weighed against the input of laser energy, which carries its own risks. With the simpler fragmentation patterns there is little risk, but also little benefit in terms of reduced ultrasound usage. With the more complex fragmentation patterns there is a greater reduction in ultrasound usage but also higher risk of gas bubble formation within the capsular bag, with the potential to cause posterior capsule rupture.

FLACS may also lead to an increased inflammatory response, as demonstrated in a study conducted by Burkhard **** MD, which showed an increased level of prostaglandins in ocular fluid following FLACS. “Many people perceived that the FLACS device is here now, in its developed form, but we are very much at the beginning of this exciting journey,” Dr Rosen said. "
Avatar universal
You are amazing in that you have so much knowledge of what the industry has to offer and the pros and cons.  I have enjoyed reading your posts here.  I too have search the internet and called manufacturers of lasers asking them for referrals to a doctor in Europe as I know that the US is behind in IOL technology.  I spoke with a well respected surgeon in Beverly Hills who said that he would not use a premium lens on my eyes, (adaptive/ multifocal) as I have had bouts of otitis over my life in both eyes which is an inflammation caused by autoimmune issues. So I feel that this is his opinion and there are other doctors that may think otherwise but you are right that to go with the oldest method is the safest.  He also is not a fan of the femtosecond lasers as they have not pressed enough to offer much more than the phase process. I have read that they are more precise, cause less inflammation and thermal artifact on tissue in the eye and offer the ability to use a precise cris cross pattern for removing the old lens.  I would love to know who you used in Europe as I am trying to find the best surgeon and IOL for my eyes as I am 53 and they cataracts are caused by steroid drops to treat Uvitis/ Iritis.  Kathy
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