Biography: Hovanesian is a faculty member at the UCLA Jules Stein Eye Institute and in private practice at Harvard Eye Associates in Laguna Hills, California.
July 03, 2018
2 min read

BLOG: Do FLACS, Zepto, miLOOP or all three?

Biography: Hovanesian is a faculty member at the UCLA Jules Stein Eye Institute and in private practice at Harvard Eye Associates in Laguna Hills, California.
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It’s now been 8 years since the U.S. approval of the first instrument for femtosecond laser-assisted cataract surgery in the United States, yet the adoption of this technology has been slowed by the cost of lasers and a lack of convincing evidence that it improves outcomes in routine cataract cases. Only one-third of U.S. surgeons regularly perform FLACS, and only 5% use it for more than 50% of their cases. Meanwhile, competing technologies have come along that create precise capsulotomies and fragment the lens without a laser. Does a surgeon who has been waiting on the sidelines need to adopt FLACS now?

One of the technologies that “competes” with FLACS is the Zepto precision pulse capsulotomy device from Mynosys, which creates a precise, centered capsulotomy using electrical energy delivered through a nitinol ring. Another is the miLOOP from Iantech, which mechanically fragments lenses without phacoemulsification energy.

Whether these devices are a complete substitute for a femtosecond laser probably depends on a few variables, including the surgeon’s practice culture, his surgical skill level, proportion of refractive cataract surgery he performs, and the mix of complicated cases in his patient population. For extraordinarily dense cataracts with a posterior nuclear plaque, nothing beats the miLOOP for fragmenting a lens. I believe this tool belongs in every operating room because of these unique benefits. However, these cases are fairly few. More common are simply dense nuclei, cases with Fuchs’ endothelial corneal dystrophy and patients with loose zonules as in pseudoexfoliation syndrome. In these, the miLOOP device offers less benefit, and it probably puts a small added stress on the zonules over normal cataract surgery. Femtosecond lasers do not. Lasers allow a reduction in phaco time and fluid turnover, which certainly benefits in these complicated eyes, as peer-reviewed studies are increasingly demonstrating.

As for the Zepto device, this is a wonderful tool for creating a perfectly centered, perfectly shaped anterior capsulotomy that has excellent strength. Regulations are coming to allow patients to pay a premium for the use of this instrument as a tool to enhance refractive outcomes. This certainly makes it an appropriate and valuable acquisition for surgeons who wish to do refractive cataract surgery, especially if they do not already have a femtosecond laser.

There are two more benefits to the femtosecond laser that can’t be ignored. First is public perception. Nothing says high tech more than the word laser. Patients immediately understand the value of FLACS at the mere description. In many places, practices performing FLACS have used it to derive a competitive advantage over those who do not. The continued sale of new lasers in the U.S., albeit at a much lower rate than before, suggests that this trend is not over.

The second benefit of having a femtosecond laser is for future technologies. Implants like the “bag in the lens” approach described by Marie-José Tassignon, the Symfony lens (Johnson & Johnson Vision) and some of the future accommodating lenses in development depend upon precise anterior and sometimes posterior capsulotomies that are only possible with a femtosecond laser. The best way to be prepared for the arrival of these lenses is to add or use a femtosecond laser now.

There’s an old saying, “While doctors debate, patients decide.” We professionals can discuss the relative merits of these different technologies, but patients have already voiced their wide acceptance of FLACS with ready adoption. Surgeons who have embraced FLACS, while few, generally remain very committed to the technique because it does deliver superb results. As excited as I am about new technologies like Zepto and miLOOP, my practice will not be letting go of our femto laser anytime soon, at least not until we upgrade to the next generation.

Disclosure: Hovanesian reports he has a financial interest in Alcon, Bausch + Lomb, Johnson & Johnson Vision, Iantech and Mynosys.