April 2019


YES Connect
FLACS adoption among young eye surgeons

by Liz Hillman EyeWorld Senior Staff Writer

Samuel Lee, MD

In the 2018 ASCRS Clinical Survey, young physicians were asked, “Given the training and/or other experience you have received thus far, how would you rate your confidence with laser-assisted cataract surgery?” 1 to 3 years of training: 35% Very Confident or Confident, fellows: 38%, less than 5 years in practice: 60%


According to the results of the 2018 ASCRS Clinical Survey, 81% of residents have not performed laser-assisted cataract surgery during their training. Being that this technology has been available to us for the better part of a decade, it is surprising that it is not more widely adopted in residency training programs. For this month’s column we spoke with three attending physicians intimately involved with residency cataract training and got their thoughts on exposing residents to this technology. Whether or not surgeons-in-training will ultimately embrace this technology in their future practice largely depends on the type of practice they join. However, I am a firm believer that residency is the perfect time to be exposed to a variety of new technologies while there is an experienced surgeon next to you to help guide you.

—Samuel Lee, MD,
YES Connect Co-Editor

The FDA approved the use of a femtosecond laser for various procedures in cataract surgery in 2010. Nearly a decade later, how is femtosecond laser-assisted cataract surgery (FLACS) being adopted by the young eye surgeons (YES) crowd?
With the results from the 2018 ASCRS Clinical Survey in mind, EyeWorld spoke with physicians involved in three different residency programs about the FLACS exposure in the YES group and their views on getting FLACS experience.

Jeffrey Caspar, MD

When UC Davis acquired a femtosecond laser for cataract surgery 4 years ago, Dr. Caspar spent the first 6 months getting acquainted with it himself, then started getting his residents involved. It’s relatively easy, he said, to get residents on board, with the laser company providing online and wet lab training, followed by 10 free laser patient interfaces so the resident could perform the procedure with no cost to the patient.
“My philosophy has always been that we should teach our residents with the latest technology, whatever it is at the time, and see where it goes because some of these technologies don’t go anywhere and some of them do,” Dr. Caspar said.
Femto training at UC Davis starts in the third year of residency, Dr. Caspar said. Some challenges trainees have with FLACS include the docking component and modifications to intraocular techniques. Hydrodissection, for example, needs to be gentle because laser-created bubbles and pressure could rupture the posterior capsule. Cortex removal also requires a different technique.
Overall, Dr. Caspar said he doesn’t think most ophthalmology residency programs have a FLACS component, in part because they may not have access to the laser. In terms of FLACS confidence, he thinks that could take 30–50 cases, which he added is not practical within most residency programs.

Julie Schallhorn, MD

All third-year residents at the UC San Francisco become certified in FLACS, Dr. Schallhorn said.
“Adoption of femtosecond lasers in residency training has been spotty,” Dr. Schallhorn said, mentioning a 2017 survey that found only 44% of residency programs have residents performing FLACS before graduation.1 That said, “In terms of training, the great thing about FLACS is that the learning curve is flat. Thus, I think FLACS can be adopted by anyone, from those just out of residency to people well into their careers.”
Dr. Schallhorn said it’s important to learn about the laser, how it works, its benefits and limitations, and how it could fit into your practice. Attending a FLACS course at a national meeting is helpful, she said. Then, schedule a wet lab with one of the laser manufacturers, practicing as many times as you need to get comfortable. Once you’re ready, take the leap to patients, Dr. Schallhorn said.
“Schedule a full day (10 cases or more) of FLACS patients so you can really get the hang of it,” Dr. Schallhorn advised. “Make sure to tell patients that you are using a new technique with a laser and that you will be discussing their case with someone in the room. Verbally walk your patients through the procedure so they know what to expect and are comfortable talking and asking questions during the procedure. After that, try different incision construction and fragmentation/capsulorhexis patterns as you gain experience until you find the settings that work for you.”
According to Dr. Schallhorn, the biggest challenge for FLACS adoption is breaking out of your comfort zone.
“With any new procedure, I think about the potential it has to offer my patients compared with what I am doing,” she said.

Jose de la Cruz, MD

The University of Illinois has been using the femtosecond laser in cataract surgery since 2011.
“There are so many things we found that are beneficial not just to the outcomes of the patient, the predictability, but also in the advancement of training, the exposure,” Dr. de la Cruz said.
Here ophthalmology residents are introduced to femto from an imaging standpoint early in their first year and laser setup and docking later that first year, with wet lab and simulation training throughout the whole of their training. In their second year, residents are exposed to the parts of the surgery and how the laser can assist.
“With all these years of using the laser, we’ve found different ways in which it can help the resident, not only in the surgery itself but also their learning,” Dr. de la Cruz said.
One advantage of the laser, he continued, is its imaging capabilities. The OCT image on the machine can show tilt or lens dislocation, for example, which allows the surgeon to prepare for the possibility of related complications.
Dr. de la Cruz said the laser can assist trainees in surgical steps that they’re not yet comfortable with, allowing them to focus on improving those skills in the wet lab while still performing the steps they are comfortable with in the OR.
“You can use it as a tool to advance and make surgery more efficient in the OR, working parallel in a wet lab environment to bring skills up,” he said.

About the doctors
Jeffrey Caspar, MD
University of California, Davis

Jose de la Cruz, MD
Assistant professor of
University of Illinois

Julie Schallhorn, MD
Assistant professor of ophthalmology
University of California,
San Francisco

Contact information
: jjcaspar@ucdavis.edu
de la Cruz: jnapoli@hotmail.com
Schallhorn: jschallhorn@gmail.com


1. Yen AJ, Ramanathan S. Advanced cataract learning experience in United States ophthalmology residency programs.
J Cataract Refract Surg. 2017;43:1350–1355.

Financial interests
: None
de la Cruz: None
Schallhorn: None

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