March 2020


Yes Connect
Femtosecond laser-assisted cataract surgery and the young eye surgeon

by Liz Hillman Editorial Co-Director

Source: 2019 ASCRS Clinical Survey

Screen image showing the plan for femto, with the fragment pattern, capsule, capsular toric marks, and corneal marks for aligning the toric IOL
Source: William Trattler, MD

After the FDA approval of the use of the femtosecond laser in cataract surgery in 2010, surgeons began to debate if there is truly a contribution to surgical outcomes when it is used. Comparative papers considering refractive outcomes and rate of complications have found, overall, no significant differences when the femtosecond laser is used compared to manual cataract surgery. This is probably one of the reasons why residency training programs have not universally incorporated the use of the femtosecond laser for cataract surgery into their residents’ surgical training.
EyeWorld interviewed three surgeons to get their thoughts on the role of FLACS and the incorporation into residency training.
—Claudia Perez-Straziota, MD
YES Connect Co-Editor

While the utility of femtosecond laser-assisted cataract surgery (FLACS) is a widely discussed topic among practicing ophthalmologists, its trickle down into training and those who are early in their career is mixed.
According to one study, 44.1% of ophthalmology residency programs included FLACS as of 2017.1 The 2019 ASCRS Clinical Survey found that among respondents who were in residency, fellowship, or their first 5 years of practice, nearly 26% had neither observed nor performed FLACS and nearly 43% had observed but not performed FLACS during their training. About 33% of respondents said they were confident or very confident with FLACS. More established practicing ophthalmologists reported using FLACS in an average of 17% of their cataract patients, and more than 95% of these later-career ophthalmologists think FLACS offers clinical benefits, according to the survey.
Kendall Donaldson, MD, said she thinks resident ophthalmologists should have experience with FLACS and extracapsular cataract surgery and traditional phacoemulsification.
“All of these techniques may be considered an appropriate option in certain cases, and resident surgeons should feel confident with these various techniques by the time they complete their training,” Dr. Donaldson said. “With premium cataract surgery becoming a more common option and rapidly advancing improvements in lens options, graduating surgeons should be prepared to offer their patients the latest technology in cataract surgery.”
She also said learning the technology in residency and fellowship allows for greater supervision during a learning curve.
William Trattler, MD, said he’s a “huge advocate” for FLACS, finding it especially useful for creating a centered capsulotomy, fragmenting the lens, and making marks for alignment of toric IOLs. Dr. Trattler said he finds FLACS reduces inflammation by reducing phaco energy, and this results in less corneal edema. However, there are some differences in surgical technique with femto compared to standard phaco, and it is therefore helpful for residents and fellows to gain surgical experience with femto during their training.
At his center, Dr. Trattler said patients who elect to have a presbyopia-correcting or toric IOL have the option for FLACS included. It’s also available to patients who might want it for arcuate incisions. A recent study of 189 eyes by Denise Visco, MD, found that femtosecond arcuate incisions provided a predictable improvement in astigmatism, with 95.8% ending up with 0.5 D of astigmatism or less.2 Dr. Donaldson also uses the laser on all of her patients who have opted for astigmatism and/or presbyopia correction at the time of cataract surgery. She also uses it as a tool for some challenging cases, such as white cataracts, dense cataracts, traumatic cataracts, loose zonules, Fuchs dystrophy, and very shallow anterior chambers.
Many studies performed over the last decade have not found any significant clinical benefit of FLACS over conventional cataract surgery.3 So, it begs the question: Is the femtosecond laser on its way out of cataract surgery or here to stay?
Dr. Donaldson thinks it will remain a tool for premium cataract surgeries.
“With the decreasing reimbursement for cataract surgery, surgeons will continue to seek out upgrade options to support their practice. These upgrades are a service to our patients, as they provide additional benefits to surgery, while at the same time, they allow us to improve the financial profile for our practice,” she said.
What’s more, Dr. Donaldson said femtosecond lasers have become more affordable for physicians with companies offering options to help offset an initial, large financial commitment.
Steven Safran, MD, said he thinks FLACS is a “pretty worthless technology.”
“To me, the laser doesn’t offer any advantage over manual surgery,” Dr. Safran said, explaining that he doesn’t see refractive, safety, or efficacy benefits to using the laser in cataract surgery. He also said it can add to surgical time.
“If we’re going to teach residents how to do surgery, we need to teach them how to do things manually,” Dr. Safran said. “They are never going to have another chance to learn how to properly handle tissue, to learn how to do a proper capsulorhexis. Young surgeons will have the opportunity after they finish residency to demo different lasers, but surgeons in training have a unique opportunity to learn and gain experience in how to physically handle and manipulate tissue on live patients with experienced instructors overseeing them. There are many things that a laser cannot do and situations for which the laser cannot be utilized, and these manual skills will be necessary for any surgeon to be successful at handling complex issues, whereas using a laser is not. Many top surgeons have either abandoned FLACS or never used it, but they all have in common excellent manual skills and judgment learned from good training and experience.”
When FLACS emerged as a new technology, Dr. Safran evaluated its capabilities and, in the end, said he thought it would be like “putting training wheels on a 10-speed bike.”
“If you need training wheels, you need them, but if you don’t, they’re just going to slow you down,” he said.
As for the laser’s ability to create arcuate incisions, Dr. Safran said he thinks limbal relaxing incisions are preferable to corneal relaxing incisions because the central 8–9 mm of cornea where most femtosecond arcuate incisions are placed is less stable in its healing compared to the cornea within 1–2 mm of the limbus. This is due to the circumcorneal annulus of collagen fibrils in the limbus that stabilizes the cornea in this region, he said.4
“Relaxing incisions placed close to the limbus are tangential to these stabilizing fibers and have less chance of causing progressive irregular astigmatism than those placed within the central 10 mm of the cornea,” Dr. Safran said. “This is why we abandoned AKs for LRIs in the first place.”
With all new technologies, Dr. Safran said surgeons have to answer these questions: Is it going to benefit my patients? Is it going to benefit me? Is it something we need?
“Unless it’s going to provide something for me that I cannot do without, … unless it is cost effective, unless it’s going to make money for me, why should I buy that?” he said.
For those interested in incorporating FLACS into their practice, Dr. Trattler offered the following pearls to young eye surgeons:
• Make sure the patient is still to get good images and when preparing to treat with the laser.
• Make sure the capsulotomy is complete (incomplete capsulotomies can occur if the patient moves).
• Don’t overfill the eye or the capsular bag. During lens fragmentation there is some gas produced. This can impact the ability of fluid to egress out of the eye. Release gases behind the lens by jiggling the nucleus a bit.
• Take advantage of the landmarks femto fragmentation provides during phacoemulsification (visualize how deep you are).
• Engage the cortex and gently hold it with vacuum, then strip. There is a different motion and a different amount of force used in FLACS cases.

About the doctors

Kendall Donaldson, MD
Medical director
Bascom Palmer Eye Institute
Plantation, Florida

Steven Safran, MD
Lawrenceville, New Jersey

William Trattler, MD
Director of Cornea
Center for Excellence in Eye Care
Miami, Florida


1. Yen AJ, Ramanathan S. Advanced cataract learning experience in United States ophthalmology residency programs. J Cataract Refract Surg. 2017;43:1350–1355.
2. Visco DM, et al. Femtosecond laser-assisted arcuate keratotomy at the time of cataract surgery for the management of preexisting astigmatism. J Cataract Refract Surg. 2019;45:1762–1769.
3. Roberts HW, et al. Femtosecond laser-assisted cataract surgery: A review. Eur J Ophthalmol. 2019. Epub ahead of print.
4. Newton RH, Meek KM. Circumcorneal annulus of collagen fibrils in the human limbus. Invest Ophthalmol Vis Sci. 1998;39:1125–34.



Relevant disclosures

Donaldson: Alcon, Bausch + Lomb, Johnson & Johnson Vision
Safran: None
Trattler: Alcon, Bausch + Lomb, LENSAR, Johnson & Johnson Vision

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