August 02, 2017
3 min read

Premium surgeons still turning to femtosecond laser-assisted cataract surgery

Clinical and efficiency challenges have been settled with advancements in technology.

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When femtosecond laser-assisted cataract surgery, or FLACS, came to the United States earlier this decade, a host of new clinical and financial challenges were brought upon the premier refractive cataract surgeon. The philosophy of FLACS has changed over the last few years with improvements in software and additional features such as the Streamline process from Lensar for astigmatism management. Companies such as Lensar are thinking progressively so more can be accomplished with the femtosecond systems we currently use. Competition breeds advancements significantly. My experience has been with the Lensar exclusively, so I will share my story with FLACS technology and its enhanced use in my practice.

The future of FLACS is already here, with Lensar having its third software upgrade in 2 years with Streamline I, II and now III. Lensar initiated its iris registration capability with the Cassini corneal shape analyzer, enabling the wireless transfer of data from preoperative corneal measurements to the actual Lensar femtosecond system. Since Cassini, Streamline III now allows for other topographers such as the Pentacam HR/AXL (Oculus), OPD III (Marco/Nidek) and Aladdin (Topcon) to be integrated as well. Iris registration eliminates the need for marking the eye for cyclorotation before laser treatment and automatically modifies the treatment plan to account for cyclorotation by comparing preoperative topography reference images from the devices mentioned above with the image taken by the Lensar laser while the eye is docked in the OR live. The wireless transfer of data to the Lensar reduces time-consuming steps that reduce efficiency and prolong procedure times. Automatic transfer of data also eliminates the potential for errors in reading and writing, errors that can compromise outcomes in the end. During scanning with Lensar while the eye is docked, automatic cataract density imaging and automatic preprogrammed fragmentation patterns are selected to increase efficiency in the eye.

My top five reasons to perform FLACS

5. Many platforms are small and portable with no bed attachments, such as the Lensar, LenSx (Alcon) and Ziemer, which allows for OR use to maximize efficiency. When I converted to FLACS, my per-hour one-room procedure time with Lensar only dropped from 4.2 cases per hour to 3.8 cases per hour, which was not clinically significant.

4. Automation, especially with my Lensar experience, is quite advanced in terms of cataract density imaging, preprogrammed fragmentation patterns and preprogrammed astigmatic incision nomograms.

3. Iris registration via wireless integration through Streamline with Lensar results in fewer to no cyclorotation errors for astigmatic correction (a 10° rotation of a toric IOL can lose up to 33% of its astigmatic correction), and it eliminates the need for marking preoperatively.


2. Intraocular surgical trauma is reduced with FLACS. Several published studies have shown FLACS to cause less corneal edema in the early postoperative period, and it may cause less trauma to corneal endothelial cells over manual phacoemulsification. Macular edema as detected in the outer nuclear layer was also significantly less using femtosecond laser technology. Further published studies have shown less anterior segment inflammation due to reduction in phacoemulsification energy needed when FLACS is performed, and FLACS also allows for a significant reduction in effective phacoemulsification time, which correlates positively with preoperative lens opacity. My own experience retrospectively showed a mean decrease in effective phacoemulsification time with the Stellaris (Bausch + Lomb) from 4.6 seconds to 1.1 seconds and mean power reduction from 12.5% to 11.2% stratified for all levels of LOCS III cataract grading.

1. My No. 1 reason to perform FLACS is my astigmatism correction results for cylinder treatment up to 1.7 D showed clinical significance (P < .001) in reduction in mean absolute values of refractive astigmatism to 0.3 D. Femtosecond astigmatic incisions, at least with the platform I use, do indeed work, as I presented at the American Society of Cataract and Refractive Surgery meeting in 2016 in New Orleans.

In summary, choosing FLACS has changed the way I practice and perform refractive cataract surgery. The clinical and efficiency issues are obvious as discussed here, and the financial advantages are positive as astigmatism management brings additional revenue. So femto is alive in my hands.

Disclosure: Jackson reports he is a consultant for Lensar, Bausch + Lomb and Marco.