Cataract
Summer 2024
by Liz Hillman
Editorial Co-Director
In the decade-plus since its approval, femtosecond laser-assisted cataract surgery (FLACS) has essentially divided cataract surgeons into two camps: loyal proponents and frequent users of the technology and those who do not think that it brings value to their practice.
Many studies in peer-reviewed literature do not find that FLACS significantly improves outcomes or safety compared to conventional cataract surgery methods (with some exceptions for comorbid conditions). But EyeWorld spoke with two surgeons who say they consistently benefit from FLACS in their practice.
“I’m very bullish toward [FLACS], and I use it now more than I ever have,” said Jonathan Rubenstein, MD.
Dr. Rubenstein started to engage FLACS in 2017. The FDA approved the use of the femtosecond laser for several functions in 2010—corneal incisions, anterior capsulotomy creation, photofragmentation, and limbal relaxing incisions. In the early years after its approval, there was a lot of buzz about the new technology, but as physicians over time determined how it does (or doesn’t) fit within their practice, some of the chatter at medical conferences, for example, has waned.
Dr. Rubenstein said this loss of the initial enthusiasm is normal but this has not diminished his belief in the benefits of the technology for his patients. Initially, when something is new, it has a lot of sparkle. That novelty plus the added allure of using a laser technology earned FLACS a lot of attention. Secondly, and most impactful for adoption vs. non-adoption was the expense of the laser and the ability to access the machine.
“There are people who do not own or have ready access to the laser who do not think it is tremendously improving their outcomes or adding to their ability to grow their practice,” Dr. Rubenstein said, adding that he can see how high-volume cataract surgeons especially might have a harder time working FLACS into their surgical flow.
Dr. Rubenstein said he has a lower volume practice, performing about 10 cataract procedures on an OR day. He finds FLACS fits well into his practice.
“For me, it is not a significant time factor. It’s a value added,” he said, explaining that in the majority of his cases (75%), he uses the femtosecond laser. “I think I perform better cataract surgery with the femtosecond laser technique. I think I do very good surgery without it, but I think I offer a slightly better product for the patient with FLACS.”
One reason surgeons and studies might not see some of the added benefit with FLACS in their typical cataract cases, Dr. Rubenstein thinks, is because they might still be using the same surgical technique.
“I think what a lot of surgeons still do not realize is that surgical technique when doing femtosecond laser-assisted cataract surgery is significantly different than regular cataract surgery. If you go in with your same phaco technique after you have lasered the cataract, it doesn’t significantly change anything,” he said. “But if you utilize the laser effectively to break up the nucleus of the lens in a specific way and tailor your lens removal technique to correspond to the laser pattern, I think it’s much more efficient.”
Kendall Donaldson, MD, said that discussion regarding femtosecond laser use in cataract surgery was popular when the technology was new, as is true for many new technologies.
“At this point, most surgeons have chosen sides and have settled into a stable practice pattern,” said Dr. Donaldson, who first began using FLACS in 2011. “We have to consider cost commitments, as well. A femtosecond laser is a significant financial commitment for a practice, and this investment needs to be considered in each practice setting.”
Peer-reviewed studies and case reports support FLACS as advantageous over conventional cataract surgery in some cases with comorbid conditions.1–3
“As a cornea specialist, I think [FLACS] has special value. I use it a lot in Fuchs dystrophy patients and any patients who have corneal endothelial compromise, and that is one place where the literature does support its use. … It’s been shown that these patients have less endothelial cell loss with femtosecond laser-assisted cataract surgery,” Dr. Rubenstein said.
He said it’s helpful with white cataracts, given its ability to create an instantaneous capsulorhexis, and also in cases of high myopes and high hyperopes.
“The other time I like it is in the management of astigmatism. I primarily use toric IOLs in the management of astigmatism, however, when I have patients in whom I correct most of the astigmatism with a toric IOL but leave a small amount of residual astigmatism, I will perform a mini LRI with the femtosecond laser to touch it up. I utilize the laser for fine tuning the astigmatism correction,” he said.
Dr. Rubenstein also uses FLACS in premium, advanced-technology IOL cases. Dr. Donaldson said she uses FLACS for all of her premium IOL cases as well and in some cases of mature cataracts, Fuchs, or trauma/weak zonules. She also mentioned its use in small eyes and for astigmatic correction.
“I think the laser allows me to put less energy into the eye and allows me to manipulate the lens less during surgery,” she said, adding later that some alternatives to femto include Zepto (Centricity Vision) for capsulotomies and miLOOP (Carl Zeiss Meditec), a nitinol filament for lens pre-fragmentation. These alternative technologies, Dr. Donaldson said, are an attempt to try to capitalize on some of the benefits of the femtosecond laser (the precise capsulotomy and the ability to pre-fragment the lens) without the cost commitment of a laser purchase.
Dr. Rubenstein said that for those who are not using the femtosecond laser in cataract surgery due to efficiency/OR flow issues, technology that combines the femtosecond laser and phacoemulsification platforms for efficiency purposes will be on the market soon from some companies and in the pipeline for others.
“If someone gets a machine that combines femtosecond and ultrasound technology, you’re going to see a resurgence of interest for it,” he thinks.
Dr. Donaldson said she finds the femtosecond laser to be a “wonderful tool and luxury that can make our cataract surgery easier.” Many patients, she added, find the use of a laser during their cataract surgery an appealing concept as they associate the laser with precision and advanced technology.
“There is evidence showing that the laser can help reduce energy expenditure during cataract surgery. There is also evidence that shows the laser can create a more precise capsulotomy and more accurate LRIs relative to manual phacoemulsification,” she said. “Some smaller studies have supported the benefits of the femtosecond laser in cataract surgery, however, there are many studies that show no difference in final refractive outcomes or safety. Each practice needs to weigh the cost/benefit ratio in their specific scenario, as in many cases this may not be a feasible expenditure unless marketing strategies are implemented to offset the cost.”
Article Sidebar
I wish I had …
Tal Raviv, MD, Cataract Editorial Board member, shared what he wishes he had:
- I wish one of my cataract work-up diagnostic devices took a high-resolution face photograph (like aesthetic practices do) that auto-integrated into my EHR so I can definitively show my postops that the cataract surgery didn’t cause their wrinkles, puffiness under their eyes, or slight lid asymmetry.
- I wish there was a validated personality questionnaire that could help me avoid certain IOLs in certain patients. And I wish I had given it to [a patient] who ended up –0.50 D in a monofocal and complains bitterly that they can’t see anything in the distance.
- I wish I could put VR-type goggles on a patient, and after 10 minutes of self-directed testing, it would tell me the vision, dominant eye (how dominant), and which IOLs the patient would do best with, after having shown a simulation with the IOLs including photic phenomena. This wish may be coming true soon.
About the physicians
Kendall Donaldson, MD
Medical Director
Bascom Palmer Eye Institute, Plantation
Plantation, Florida
Jonathan Rubenstein, MD
Chairman and Deutsch Family Endowed Professor
Department of Ophthalmology
Rush University Medical Center
Chicago, Illinois
References
- Yong WWD, et al. Comparing outcomes of phacoemulsification with femtosecond laser-assisted cataract surgery in patients with Fuchs endothelial dystrophy. Am J Ophthalmol. 2018;196:173–180.
- Teshigawara T, et al. The advantages of femtosecond laser-assisted cataract surgery for zonulopathy. Int Med Case Rep J. 2019;12:109–116.
- Assaf AH, et al. Femtosecond laser-assisted cataract surgery in soft and hard nuclear cataracts: a comparison of effective phacoemulsification time. Clin Ophthalmol. 2021;15:1095–1110.
Relevant disclosures
Donaldson: AbbVie, Alcon, Bausch + Lomb, BioTissue, Carl Zeiss Meditec, Dompe, Eyevance, Johnson & Johnson Vision, Kala, LENSAR, Lumenis, Omeros, Oyster Point, PRN, Quidel, Science-Based Health, Sun, Tarsus, Versea
Rubenstein: Alcon
Contact
Donaldson: KDonaldson@med.miami.edu
Rubenstein: Jonathan_Rubenstein@rush.edu
