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The Role of FLACS in 2017

Clinical Associate Professor Michael Lawless | 1 December 2017
There are many different surgical devices and techniques used by individual surgeons which suit them and their patient cohort. Femtosecond laser-assisted cataract surgery is one of them, which offers particular advantages.

Clinical Associate Professor Michael Lawless

Femtosecond laser-assisted cataract surgery (FLACS) was introduced to Australia in early 2011. The precision and reproducibility of a laser capsulotomy and the reduction in phacoemulsification energy during FLACS have been well documented, with evidence of faster visual recovery and more stable refractive results.1 

Australian surgeons have contributed to the world literature, and were helpful in educating surgeons about early problems with capsular block syndrome, imperfect capsulotomies, and the risk of capsular tears. Advances in laser technology, patient interfaces and surgical technique have resolved these issues with no further cases of capsular block recorded since 2012, and large studies on different platforms reporting close to a 100 per cent rate of achieving a round, free-floating capsulotomy with an anterior capsular tear rate of 1:1000.2,3

I personally use FLACS in approximately 90 per cent of cataract and refractive lensectomy cases. I particularly feel it gives me an advantage in certain anatomical circumstances, such as high hyperopes with shallow chambers and patients with floppy iris syndrome, since the capsulotomy and nucleus division is performed prior to entering the eye. I also feel it gives me an advantage when the corneal endothelium is compromised. FLACS has fundamentally altered how we treat posterior polar cataracts. Vasavada et al’s femtodelineation technique is simply a better way to approach these cases.4 High resolution imaging of the cataract during laser planning and the multiple programmable fragmentation patterns available have started to allow us to tailor FLACS surgery to individual cataract types.

I also enjoy using FLACS in routine cases. For example, a 60 year old refractive lensectomy trifocal intraocular lens patient: here it provides me with a level of comfort that the capsulotomy is performed perfectly, placed where I want it to be, 5.1mm in diameter, so I’ll have exactly the right type of capsule coverage of the optic of the IOL. I’m clearly not alone as approximately 10 per cent of cataract surgeries in Australia are performed using FLACS, a very similar number to the United States. It comes down to a surgeon preference. There are many different surgical devices and techniques used by individual surgeons which suit them and their patient cohort. 

The benefits of FLACS over manual phacoemulsification are incremental. To prove these benefits will take time and well-designed studies.5 The French FEMCAT multicentre prospective randomised study should help. Sponsored by the French Ministry of Health, this is the largest RCT so far, with 1,000 patients randomised shortly before surgery to having bilateral FLACS or bilateral phacoemulsification. Study patients did not pay extra for FLACS and sham laser docking with manual phacoemulsification kept all patients masked to their treatment.6 One-year postoperative data are being analysed at this time with data presented at the recent ESCRS in Lisbon. Dr. Schweitzer, who presented the preliminary results, was quoted as saying: “there were no significant differences between femto and phaco. There was a slight trend to a lower rate of postoperative cystoid macular edema in the femto group, and the overall success rate of the two procedures was equal.”7

Cataract surgery is a common operation and society demands that it be extremely safe and effective. FLACS is an attempt to make a good operation better. Further refinements in how it is delivered  may demonstrate superiority but at the end of 2017, it remains a choice for surgeons and patients.

Clinical Associate Professor Michael Lawless was one of the first ophthalmic surgeons in the world and the first surgeon in the Southern Hemisphere to perform femtosecond laser for cataract surgery. His areas of specialisation are laser vision correction, cataract surgery, lens surgery, refractive lens exchange and corneal transplants.

1. Conrad-Hengerer I, Al Sheikah M, Hengerer FH, et al. Comparison of visual recovery and refractive stability and the femtosecond laser-assisted cataract and standard phacoemulsification:  Six month follow-up; Journal of Cataract and Refractive Surgery 2015; 41:1356-64.
2. Day AC, Gartry DS, Maurino V, et al.  Efficacy of anterior capsulotomy creation in femtosecond laser-assisted cataract surgery. Journal of Cataract and Refractive Surgery 2014; 40:2031-4.
3. Roberts TV, Lawless M, Sutton G, et al.  Anterior capsule integrity after femtosecond laser cataract surgery. Journal of Cataract and Refractive Surgery 2015; 41:1109-10.
4. Vasavada AR, Vasavada A, Vasavada S, et al. Femtodelineation to enhance safety in posterior polar cataracts.  Journal of Cataract and Refractive Surgery 2015; 41:702-7.
5.  Roberts TV. Editorial: Femtosecond lasers in Cataract Surgery.  Clinical and Experimental Ophthalmology 2016; 44: 545-546.
6. Chang D. Editorial: Does femtosecond laser–assisted cataract surgery improve corneal endothelial safety? The debate and conundrum. Journal of Cataract and Refractive Surgery 2017;43:440-442
7. Schweitzer C. Evidence from the French FEMCAT study. Presented at European Society of Cataract and Refractive Surgeons meeting; Oct. 7-11, 2017; Lisbon, Portugal.

  • Optical coherence imaging of lens during FLACS allowing for customisation of laser approach (Top and bottom left: thick lens nucleus, Top right: Posterior polar cataract, Bottom left: dense white cataract)
  • Fragmentation patterns Alcon LenSx

' FLACS is an attempt to make a good operation better. Further refinements in how it is delivered may demonstrate superiority '