Does FLACS cost, benefit outweigh manual? No!

Reviewed by Rosa Braga-Mele, MD

Femtosecond laser-assisted cataract surgery (FLACS) offers some advantages compared with a conventional manual procedure, particularly for certain patients. Currently, however, FLACS does not result in superior outcomes and it has drawbacks that outweigh its benefits, according to Rosa Braga-Mele, MD.

“I am using FLACS, and I really like it, but FLACS adds financial and clinical challenges,” said Dr. Braga-Mele, professor of ophthalmology and vision sciences, University of Toronto, Ontario.

Discussing cost, Dr. Braga-Mele noted data from multiple studies show that, at least initially, FLACS increases costs.

“Theoretically, the extra costs can be passed on to the patient under certain insurance exceptions or as a refractive procedure,” she said. “However, I would urge surgeons who are considering the purchase of a femtosecond laser to perform a financial analysis for their center.”

Clinical challenges

Dr. Braga-Mele first cited a learning curve so that surgeons can initially expect to spend an additional 5 to 7 minutes on each case.

The extra time needed should be considered with the effects FLACS has on workflow.

“Surgeons need to think through logistical hitches to avoid bottlenecks,” she said. “Consideration has to be given to where the laser will be installed, including the potential need for a separate room. Scheduling will need to take into account how many surgeons will be using the laser and how many procedures will be booked.”

Surgeons also need to be aware that femtosecond laser treatment induces prostaglandin release that may cause pupillary constriction. They should be prepared to manage miosis by having a pharmacological adjunct on hand.

Awareness of other potential complications associated with FLACS supports the use of specific surgical techniques. Dr. Braga-Mele recommended pulling the laser-created capsulotomy centrally to minimize the potential for radial tears.

Posterior capsule rupture

To avoid posterior capsule rupture during hydrodissection, particularly in eyes with a posterior polar cataract, she advocated performing gentle decompression of the intralenticular air bubbles created by the laser treatment.

In addition, surgeons should be prepared for cortex removal to be more challenging.

“The edge that is present after manual capsulorhexis is lacking when the femtosecond laser is used for capsulotomy,” she said. “Surgeons may have to re-learn how to do a tangential sweep and may find it necessary to go a little farther underneath the capsule rim than they might feel comfortable doing.”

The release of prostaglandins with FLACS has also been associated with increased indices of inflammation, including a trend toward more cystoid macular edema.

In addition, FLACS may worsen dry eye.

“These issues require further study, but they are something to consider when using FLACS, especially in premium cases,” Dr. Braga-Mele said.

Large studies comparing FLACS with conventional surgery failed to find that FLACS was superior. Data from a case-control study conducted by the European Society of Cataract and Refractive Surgeons showed FLACS was safe but did not outperform manual surgery.

A meta-analysis including data from 14,567 eyes determined there were no statistically significant differences between FLACS and conventional surgery with respect to patient-important visual and refractive outcomes and complications [Popovic M et al. Ophthalmology. 2016;123:2113-2126].

The review identified statistically significant differences favoring FLACS in analyses of effective phacoemulsification time, capsulotomy circularity, postoperative central corneal thickness, and corneal endothelial cell reduction.

However, FLACS was associated with higher prostaglandin concentrations and higher rates of posterior capsular tears. Dr. Braga-Mele said despite its limitations, FLACS is here to stay, and offered some ideas to make it better.

“We need to lower the cost to ourselves and our patients,” she said. “We need platforms with a smaller footprint that will fit in the operating room and make FLACS more convenient for the patient and the surgeon.”

Rosa Braga-Mele, MD

E: rbraga-mele@rogers.com

This article was adapted from Dr. Braga-Mele’s presentation at the 2016 meeting of the American Academy of Ophthalmology. Dr. Braga-Mele is a consultant to companies that market femtosecond lasers for cataract surgery.