March 28, 2017
2 min read
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FLACS excels in some niche applications

Removal of hard cataracts is one area in which FLACS is advantageous.

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KOLOA, Hawaii — For some niche applications, femtosecond laser-assisted cataract surgery is “clearly superior” to manual methods of phacoemulsification, according to Randall J. Olson, MD, who discussed the impact of FLACS on standard of care at Hawaiian Eye 2017.

“The big question at this point is, is it better?” he asked. “We know it adds expense. We know it adds time. It must be adding something or all of you wouldn’t be trying it, and a lot of people wouldn’t be talking about it.”

Olson pointed to three key publications to help answer the question: the American Academy of Ophthalmology 2016 Cataract Preferred Practice Pattern, his own editorial in the American Journal of Ophthalmology and a meta-analysis by Popovic and colleagues in Ophthalmology, which concludes that there were no statistically significant differences between FLACS and manual cataract surgery regarding corrected or uncorrected distance visual acuity, but that FLACS was associated with higher rates of posterior capsular tears.

Randall J. Olson

Better results

The lesson learned from these references is that there are areas where the overall evidence points to there being some superiority with FLACS, Olson said.

“Less energy is required to remove harder cataracts. I think that’s an advantage,” Olson said. “If carefully studied, I think it could be shown that in that niche of really hard cataracts, there’s probably a big advantage.”

A more precise and centered capsulorrhexis is another FLACS advantage, as is the procedure’s utility in eyes with loose zonules and other complicated cases.

“Clearly, these are niche categories,” Olson said.

Equivalent results

Areas where the two methods are equivalent include refractive outcomes and rates of complication, Olson said. Early work suggested that having a perfect capsulorrhexis could have a big advantage in refractive results, but “if there is, it’s probably like 1/20th of a diopter,” he said, adding that any small difference between the two groups “seems to be lost in the noise.”

Comparisons are difficult, however, because complication rates for manual phacoemulsification are “extremely low,” Olson said. “Phaco is a tough control group. ... Even with these larger studies, besides being retrospective, they really aren’t powered enough to see some of these differences.”

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Worse results

FLACS is not an advantage with regard to time and money.

“No one is going to argue with me that it’s worse [in that] it adds expense and it adds time,” Olson said.

Additionally, some studies show increased prostaglandin levels and more capsular problems with FLACS.

“We need to remember, though, that we’re comparing an evolving technology with a mature technology and that creates some difficulties,” Olson said. “So the jury is out. ... Supporters of [FLACS] need to push for and give us better studies, particularly ... randomized trials where we can get a little better idea of where [the two methods] meet head to head.” – by Patricia Nale, ELS

Disclosure: Olson reports no relevant financial disclosures.