Published: 2023-04-11

Progress in the treatment of cataract - from Ultrasound to a new revolutionary step to LASER surgery: A femtosecond laser that works quietly, elegantly, and silently, without vibration and heat. In this case, the affected area is microscopic – 5 microns, and there are no effects on the surrounding tissues of the eye.




How does a person usually find out about a problem? They go to the optometrist for many years, and eventually the moment comes when the doctor shrugs and says: “I can’t help you with glasses or contact lenses anymore, it’s time for an ophthalmologist.” As a rule, a preliminary diagnosis is done, and in 90% of cases it is confirmed: cataracts. With that we often find problems that the optometrist did not notice: diabetic retinopathy, macular degeneration, and glaucoma. And when the cataract finally reaches the point of no return, the patient decides whether to have surgery or not.

There are four reasons one might consider a cataract corrective procedure. The most common: decreasing vision. A driver cannot see well at night, the photographer, artist or dentist no longer see that which without makes their profession impossible. A person might also just want to see better.

The second reason is when the cataract begins to swell, which leads to increased pressure and glaucoma. There might not be much of a choice in this instance, surgery is a must.

The third reason is when the doctor needs to see the ocular fundus for the treatment of glaucoma or retinal detachment. It may not be otherwise possible due to a cloudy cataract.

Lastly, the cataract may already be so neglected that it begins to decompose. These last three reasons are only around 10% of cases, and 90% are the patient’s desire to improve eyesight.

What happens next? Here at the Eye Center we have the following principle: the patient must see what we see. We are investing large resources in the acquisition of imaging machines, which allow patients to see cataracts, their own retina, etc. And we explain how it all works or stops working. At the next stage you decide: yes, I want an operation, or not. If you choose to have it, you need to also decide on how to do it.


What did cataract surgery look like 50 years ago? A large incision of 180 degrees was made, on almost half of the eye, and the lens extruded out of it like the pit of a cherry. This required, as you may remember from your grandparents, a 5-10-day hospitalization. Patients lay without unnecessary movements, waiting for wounds to heal from sutures after incisions. Then there was a revolution of the Ultrasound. The procedure was called phacoemulsification, invented by Dr. Charles Kelman. Once, his dentist was brushing his teeth with ultrasound, which beats the stones without destroying the tooth, and Kelman was enlightened: what if the cataract inside the eye is crushed through an incision?

For the next forty years, ultrasound needles were the last word in science and technology. The incisions gradually decreased: 12 mm, 7 mm, and for ten years now, a 2-mm incision through which an intraocular lens is implanted.


Everything seemed to be fine, but not quite. Ultrasound does not stop at a destroyed cataract, and continues to move through the eye. Like a stone thrown into a pond, waves from which run to the shore, sound waves cannot be stopped.

There are many vulnerable tissues in the eye, such as the retina, optic nerve, but the most sensitive is the cornea. Therefore, a not so rare complication after ultrasound is corneal decompensation. On its inner side there are so-called endothelial cells, which constantly remove fluid from it. The cornea is like a ship in which a leak forms all the time, and there is a pump that drains this liquid. If the pump breaks, the ship sinks. If moisture is not emptied out of the cornea, it will swell and become cloudy.


Endothelial cells, once dead, do not regenerate. All of us in childhood heard or read that nerve cells are not restored. Now we know that this applies not only to the neurons. We are born with 4 thousand cells per square millimeter. When there are less than 1,800, the cornea begins to swell. Firstly, it is as if seeing through a foggy glass; and secondly, eye pain. The problem caused by ultrasound surgery had to be solved by corneal transplantation, and this is an invasive operation, with donor tissue and has a high risk of complications. Isn’t it better to avoid it?

Surely, in the hands of a good surgeon, the risk of any complications is minimized. But there are no tricks against physics. If you are over 70 and have already lost a lot of endothelial cells, then, going for an ultrasound surgery is a serious risk. Typically, 70-75-year-olds no longer have 4 thousand cells per millimeter, but 2 thousand. It will not take much ultrasound to knock these cells off the cornea and cause decompensation. With that, complications will arise regardless of the quality of the surgeon.


Despite the fact that phacoemulsification made it possible to make a small incision and achieve good vision immediately post-surgery, it was clear that sooner or later a better method would appear. Around 10 years ago a new revolution came about: A femtosecond laser was invented, which crushes a cataract with a ray of light. A laser that works quietly, elegantly, silently, without vibration and heat. In this case, the affected area is microscopic – 5 microns, and there are no effects on the surrounding tissues of the eye.

A laser surgery performed under the guidance of a surgeon, on the one hand, and under the control of computer measurements, on the other, reduces the risk of complications to almost zero. The laser turns the cataract into jelly, and the capsule opens with such precision, as if you were working with a compass, although no compass has ever dreamed of such accuracy. Astigmatism is corrected, the smallest incisions are made with such precision that they close by themselves, and no seams are needed.


All of this brought cataract surgery to a completely different level. But not every technological revolution is immediately accepted. 10 years ago it was hard to believe that by paying $2 million for a laser, and by paying a laser company $1500 for each use with this laser, the doctor could stay afloat.

What was the first reaction? “They just want to trick us! Here I am – such a great surgeon and such a wizard that I do not need your lasers. I will make ultrasound a pleasure to see. Ultrasound is second to none.” I myself thought something like that at the beginning. And at that time, there was a heated debate at conferences, where 90% of conservative participants argued with 10% of progressives. The conservatives said: “You are fools who bought a fabulously expensive machine to do the same thing that we, the magicians of ultrasound, do without. You need to have skills and talent, not new machines!” And 10% answered: “Guys, after all, 30 years ago your predecessors said the same thing about ultrasound. They shouted that they are surgeons from God who can sew huge incisions with their hands without any ultrasound. ”


At our Beverly Hills Surgical Center, everything should be – and is – the most advanced in the western world. From doctors to equipment. So we even have not one, but two lasers from two competing companies, worth $2 million each. And while we were doing laser procedures for almost 10 years, many of us began to slowly collect data and compare the results.

One doctor makes an incision with a brand new, sharp, sterile little blade, the other with the laser. Then you roll out the patient into the light – and they are delighted. You roll out the other patient – they too are delighted. So what? But let’s see what happens in a week, a month, six months, 10 years. And we cannot close our eyes to the results, as it is no longer possible to state with a clear conscience that there is no difference. The results are obvious for the surgeon, just as they are for the patient.


With laser surgery, the risk is MANY TIMES less. Actually, “many times” – that is to say dozens of times less. With a laser, the risk of decompensation of the cornea is negligible, and the results of visual acuity are much better. By the way, many do not know that 50-60% of Russian immigrants and people with Scandinavian roots have weak suspensory ligaments of the lens. Therefore, after 45-50 years, pseudoexfoliation syndrome often develops: the lens begins to wobble. And if under such conditions your loose capsule and weak suspensions start getting thrashed with ultrasound, then complications are guaranteed. Even if a good surgeon is operating, on average after 9 years your lens will “hang by a thread”. And you have to do a complex two-hour operation, which only a few surgeons in this city can do, and I am one of them. At the same time, we must take into account that the patient is no longer 75, but approaching 90. But if the operation was done with a laser, then even with weak suspensions and impaired stocks of endothelial cells – everything will be fine with you.


Therefore, from January 1, I made a choice. I no longer want to offer patients an operation that is not only not the best, but also carries an increased risk. Some people drive their cars unfastened, I never do this, and I don’t drive children without car seat. And if you trust me as a specialist, then keep in mind the difference between the operations, which cannot be ignored. Yes, there are doctors who have convinced themselves of the opposite and even claim that ultrasound is better. I say to this a firm NO, because the principle of “Do no harm” has not been canceled yet. Eyes are not teeth, and you will not buy yourself a new eye instead of a lost one even for a billion. The price of laser surgery is not so high that someone could not afford it.

If you come to us with the words: “Doctor, I want to see better”, then how can I intentionally provide you with not the best of the existing operations? But if you do not want it, then I may recommend a list of other doctors. They are good people and want the best, despite the fact that it does not always work out. At the same time, we at the Benjamin Eye Institute understand that these two thousand dollars are not the same for everyone, so there are all kinds of discounts, installments, etc. It’s worth considering not twice, but seven times before deciding on your priceless eyes.

Our goal here coincides with yours: to achieve a vision that makes a person happy.

Arthur Benjamin