Femtosecond Cataract Surgery

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Article initiated by:

Douglas M. Wisner, MD

All contributors:

Alpa S. Patel, M.D., Douglas M. Wisner, MD, Derek W DelMonte, MD, David Glasser

Assigned editor:

Joseph Christenbury, MD

Review:

Assigned status Update Pending

 by Derek W DelMonte, MD on November 6, 2022.

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Contributing Editors:	add

Femtosecond laser assisted cataract surgery (FLACS) is a recent development in the history of cataract surgery. The femtosecond laser can be used to create cleavage planes via photodisruption in transparent/translucent tissues, focused with the aid of real-time intraoperative imaging (optical coherence tomography (OCT) or scheimpflug).

Indications

To date, the laser can be used to assist the surgeon by creating tissue planes for:

1. Wounds
2. Arcuate keratotomies
3. Anterior capsulotomies
4. Nuclear fragmentation.

Outcomes

Available evidence indicates that FLACS does not carry additional risk compared to non-FLACS small incision phacoemulsification cataract surgery. FLACS can offer a greater level of precision and repeatability for creation of tissue planes than manual techniques. As a result, FLACS is thought, and in some cases has been shown, to offer more precise incisional astigmatism management (wounds and arcuate keratotomies), lens centration (capsulotomy) and reduced effective phaco energy (nuclear fragmentation). However, clinical outcomes of FLACS have not been demonstrated to be superior to those of traditional phacoemulsification surgery. Economic analyses have shown FLACS to be less cost-effective.

The cost of the laser to surgeons/surgery facilities is significant. Currently, surgeons may only charge patient (out of pocket, not reimbursed by insurance) for use of the laser for intraoperative imaging (in the case of advanced technology (toric and presbyopia correcting) intraocular lenses) and astigmatism management (via keratotomies). There is evidence that FLACS can predictably manage lower levels of astigmatism for patients electing this correction at the time of cataract surgery, and can improve patient outcomes with presbyopia correcting IOLs. There is not sufficient evidence at this point in time to suggest that FLACS offers better outcomes than non-FLACS small incision phacoemulsification cataract surgery for standard cases with a basic monofocal (non-toric) IOL, or that FLACS is cost-effective for all cases. There is some evidence to suggest that FLACS improves safety and patient outcomes in select medical conditions (Fuchs/dense corneal guttata, subluxed crystaline lens, mature/advanced cataract, etc.), but charging for the use of the laser solely for medical reasons in these settings is not approved.

Additional Resources

• American Academy of Ophthalmology. Review of femtosecond laser-assisted cataract surgery Editors' Choice. San Francisco: American Academy of Ophthalmology, 2014. Accessed February 06, 2023.
• American Academy of Ophthalmology Ophthamic Technology Assessment. Femtosecond-laser assisted cataract surgery. Ophthalmology 2022;129:946-954.