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Femto or not, here I come: Premium surgeons take heed

Femtosecond laser-assisted cataract surgery positively affects all levels of the cataract procedure.

The song “Ready or Not Here I Come (Can’t Hide from Love)” produced in 1968 and sung by The Delfonics is what comes to my mind as a premium surgeon when thinking what technology is best for my patient outcomes. Do the following comments and concerns about femtosecond laser-assisted cataract surgery, or FLACS, sound familiar?

The technology is not any better than our current methodology.

There is no peer-reviewed literature supporting the benefits of FLACS.

It is not worth the additional time.

The bad news for the naysayers of FLACS is there is plenty of support by clinical experience and peer-reviewed literature to the contrary of their beliefs in terms of corneal safety, capsulotomy precision, lenticular fragmentation, astigmatic management and complex case benefits.

Corneal safety

The most important objective variable on postoperative day 1 after cataract surgery is the degree of corneal edema because this translates into the true “wow” factor subjectively in terms of uncorrected distance visual acuity (UDVA). Several presentations and publications have repeatedly shown less corneal endothelial cell loss, lower effective and absolute phacoemulsification times (EPT and APT), lower cumulative dissipated energy (CDE) and lower total volume of balanced salt solution fluid used when FLACS has been implemented, all translating to better UDVA on day 1 after surgery. This benefit becomes even greater in patients with already-compromised endothelium such as those with Fuchs’ corneal dystrophy.

Superior capsulotomy

Precise capsulotomy using FLACS allows for better IOL centration and better effective lens position (ELP), such that a 0.5 mm axial plane deviation from the intended ELP can result in a 1 D refractive error. FLACS even allows placing the capsulotomy on the visual axis or pupillary axis, the former more critical when placing multifocal, extended depth of focus or trifocal IOLs when patients have a higher angle kappa or alpha.

Lenticular fragmentation and complex cases

FLACS-related lens fragmentation results in lower CDE from less ultrasound power in the eye from phacoemulsification, less endothelial cell loss, less corneal edema, and less risk for capsular rupture and vitreous prolapse, all leading to faster visual recovery. I presented at the American Society of Cataract and Refractive Surgery meeting in Washington earlier this year on a retrospective two-arm (FLACS vs. no FLACS), single-surgeon 322 eye study showing the advantages of multiburst mode on a Stellaris vision enhancement system (Bausch + Lomb) when used with FLACS vs. no FLACS on early postoperative outcomes. LOCS III cataract grading was performed preoperatively to show stratification of effects depending on density of the cataract. EPT, APT and total balanced salt solution fluid used were all better statistically and corneal edema was statistically less when FLACS was utilized, with the biggest take-home result being the UDVA on postoperative day 1 was on average three lines better. Certain femtosecond platforms such as Lensar (Lensar) utilize Scheimpflug imaging to help create fragmentation patterns based on lens density as well, which minimizes excess energy delivery when not needed during fragmentation. All these benefits become even more beneficial in complex cases such as pseudoexfoliation, mature white, posterior polar, dense brunescent and traumatic cataracts. Less manipulation is needed during phacoemulsification in these more compromising cases.

Astigmatism management

Many papers have been presented and published showing the enhanced precision of FLACS-created corneal arcuate incisions for the correction of astigmatism up to 1.5 D with minimal risk for perforation and/or irregular astigmatism changes seen with manual incisions. The most recent breakthrough with FLACS astigmatism management is the creation of a pair of small tabs on the anterior capsular rim during the laser capsulotomy part of FLACS. These small tabs, opposite 180° to one another, assist premium surgeons in accurately aligning toric IOL marks along the predefined axis of astigmatism. Any toric IOL can be used, but only the Lensar platform currently creates such tabs. Precise toric IOL placement is critical because every 1° of misalignment can lead to 3.3% loss of correction. Conjunctival ink marks are imprecise, can run and even can disappear once the patient is supine on the operating table. External corneal laser marks are an improvement, but pseudo-alignment may occur due to off-axis observation through the microscope, creating unwanted parallax errors.

OR efficiency maintained

My surgery center did a retrospective time analysis of OR efficiency once FLACS was adopted. To our surprise, with the Lensar platform (which has no attached bed) and staying in one room, we only decreased from 4.2 cataract cases per hour to 3.8 cases per hour, but with the increased advantages of FLACS discussed here and with enhanced revenue in a declining reimbursement era.

In summary, FLACS affects all levels of the cataract procedure, enhances safety, improves day 1 visual outcomes and makes all types of cataract procedures that much easier for even the premium surgeon. So take heed, ready or not FLACS is here to stay.

Disclosure: Jackson reports he is a consultant for Lensar, Bausch + Lomb and Alcon and a speaker for Johnson & Johnson.

The song “Ready or Not Here I Come (Can’t Hide from Love)” produced in 1968 and sung by The Delfonics is what comes to my mind as a premium surgeon when thinking what technology is best for my patient outcomes. Do the following comments and concerns about femtosecond laser-assisted cataract surgery, or FLACS, sound familiar?

The technology is not any better than our current methodology.

There is no peer-reviewed literature supporting the benefits of FLACS.

It is not worth the additional time.

The bad news for the naysayers of FLACS is there is plenty of support by clinical experience and peer-reviewed literature to the contrary of their beliefs in terms of corneal safety, capsulotomy precision, lenticular fragmentation, astigmatic management and complex case benefits.

Corneal safety

The most important objective variable on postoperative day 1 after cataract surgery is the degree of corneal edema because this translates into the true “wow” factor subjectively in terms of uncorrected distance visual acuity (UDVA). Several presentations and publications have repeatedly shown less corneal endothelial cell loss, lower effective and absolute phacoemulsification times (EPT and APT), lower cumulative dissipated energy (CDE) and lower total volume of balanced salt solution fluid used when FLACS has been implemented, all translating to better UDVA on day 1 after surgery. This benefit becomes even greater in patients with already-compromised endothelium such as those with Fuchs’ corneal dystrophy.

Superior capsulotomy

Precise capsulotomy using FLACS allows for better IOL centration and better effective lens position (ELP), such that a 0.5 mm axial plane deviation from the intended ELP can result in a 1 D refractive error. FLACS even allows placing the capsulotomy on the visual axis or pupillary axis, the former more critical when placing multifocal, extended depth of focus or trifocal IOLs when patients have a higher angle kappa or alpha.

Lenticular fragmentation and complex cases

FLACS-related lens fragmentation results in lower CDE from less ultrasound power in the eye from phacoemulsification, less endothelial cell loss, less corneal edema, and less risk for capsular rupture and vitreous prolapse, all leading to faster visual recovery. I presented at the American Society of Cataract and Refractive Surgery meeting in Washington earlier this year on a retrospective two-arm (FLACS vs. no FLACS), single-surgeon 322 eye study showing the advantages of multiburst mode on a Stellaris vision enhancement system (Bausch + Lomb) when used with FLACS vs. no FLACS on early postoperative outcomes. LOCS III cataract grading was performed preoperatively to show stratification of effects depending on density of the cataract. EPT, APT and total balanced salt solution fluid used were all better statistically and corneal edema was statistically less when FLACS was utilized, with the biggest take-home result being the UDVA on postoperative day 1 was on average three lines better. Certain femtosecond platforms such as Lensar (Lensar) utilize Scheimpflug imaging to help create fragmentation patterns based on lens density as well, which minimizes excess energy delivery when not needed during fragmentation. All these benefits become even more beneficial in complex cases such as pseudoexfoliation, mature white, posterior polar, dense brunescent and traumatic cataracts. Less manipulation is needed during phacoemulsification in these more compromising cases.

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Astigmatism management

Many papers have been presented and published showing the enhanced precision of FLACS-created corneal arcuate incisions for the correction of astigmatism up to 1.5 D with minimal risk for perforation and/or irregular astigmatism changes seen with manual incisions. The most recent breakthrough with FLACS astigmatism management is the creation of a pair of small tabs on the anterior capsular rim during the laser capsulotomy part of FLACS. These small tabs, opposite 180° to one another, assist premium surgeons in accurately aligning toric IOL marks along the predefined axis of astigmatism. Any toric IOL can be used, but only the Lensar platform currently creates such tabs. Precise toric IOL placement is critical because every 1° of misalignment can lead to 3.3% loss of correction. Conjunctival ink marks are imprecise, can run and even can disappear once the patient is supine on the operating table. External corneal laser marks are an improvement, but pseudo-alignment may occur due to off-axis observation through the microscope, creating unwanted parallax errors.

OR efficiency maintained

My surgery center did a retrospective time analysis of OR efficiency once FLACS was adopted. To our surprise, with the Lensar platform (which has no attached bed) and staying in one room, we only decreased from 4.2 cataract cases per hour to 3.8 cases per hour, but with the increased advantages of FLACS discussed here and with enhanced revenue in a declining reimbursement era.

In summary, FLACS affects all levels of the cataract procedure, enhances safety, improves day 1 visual outcomes and makes all types of cataract procedures that much easier for even the premium surgeon. So take heed, ready or not FLACS is here to stay.

Disclosure: Jackson reports he is a consultant for Lensar, Bausch + Lomb and Alcon and a speaker for Johnson & Johnson.

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