Hello Femto!

Back in the early days of phacoemulsification technology, there were people who didn’t believe in it. Now, we have ‘naysayers’ who say femtosecond laser-assisted cataract surgery (FLACS) has reached its peak. But I believe FLACS is here to stay.

I am a ‘femto guy’ – I use it in over 80 percent of my cases. Why? Because it offers me better outcomes for my patients than conventional phaco surgery. In terms of safety, FLACS delivers less energy into the eye, and is associated with less endothelial cell loss, corneal edema and a 50 percent lower rate of vitreous loss (1)(2)(3). Most importantly, FLACS delivers significantly faster visual recoveries to patients; one day after surgery, FLACS patients who had dense cataracts removed can see three lines better than patients who received phaco surgery (4). FLACS also has superiority as a cataract refractive tool. As effective lens position is partially determined by where you place the capsulotomy – important for multifocal or EDOF lenses – an advantage of FLACS is that the capsulotomy can be centered more precisely on the optic axis. There’s no way a manual capsulorhexis can be placed as perfectly! Also, astigmatism can be managed using femto through the placement of precise, customized arcuate incisions. Recently, LENSAR received approval to create anterior capsule ‘nubs’ to enhance accuracy of alignment when toric IOLs are used for astigmatism correction. Cyclorotation errors are minimized significantly with this new femto adjunct to my armamentarium.

So what are the naysayers saying about FLACS? Cost is admittedly the biggest disadvantage, but if you’re a high volume cataract surgeon, this is not so much of an issue. Sure, if you’re only performing one or two procedures a month, it doesn’t make much financial sense to own a laser. But if you’re not a high-volume surgeon, FLACS is not inaccessible; if you have a nearby center you can pay a ‘per click’ fee to use the technology. At my center, I’m happy to let anyone use the femto systems once they’re certified.

Another commonly reported disadvantage of FLACS is time efficiency. In my practice, we went from 4.2 cases an hour to 3.8 cases when we converted to FLACS. But from that small amount of time efficiency lost, I’ve gained a lot by having better surgical outcomes and happier patients, which to me is a huge offset. There are also many ways to maximize efficiency of FLACS in your OR – I call mine the ‘no motion efficiency system’. I have all equipment in one room, and as my system doesn’t have a detachable bed, I sit in the same spot and the patient can be slid in head- or feet-first depending on which eye is being operated on; there is no movement of equipment between cases, which saves time.

It is true that lower cost technologies exist, such as Zepto (Mynosys), but you’ve got to remember that you’re not gaining access to lens fragmentation or astigmatic treatment; you’re just getting a capsulotomy. miLOOP (Iantech) offers lens fragmentation, reduces phaco time, and it is extremely useful for dense cataracts; but even so, miLOOP doesn’t do all the things that femto can do – it’s more of an adjunct. Both Zepto and miLOOP add a nominal cost to the procedure which, in the US, isn’t billable to the patient unlike use of femto, which is billable to the patient as long as astigmatic correction is performed.

In short, I believe that FLACS is ‘alive and kicking’ and has multiple advantages for both surgeons and patients alike. I think that as long as the big companies keep supporting the technology and driving it forwards, FLACS is here to stay. I would like to see it continue to move forward as it has done a lot for my patients – I am a ‘pro-femto’ guy, after all, and I’m excited to see what else may be on the horizon.

Jackson reports that he is a consultant for Bausch & Lomb and LENSAR.