Over this last year of practice, I have been incorporating femtosecond laser-assisted cataract surgery (FLACS) for a large proportion of my cataract surgery patients. In this article, I will discuss the advantages of incorporating FLACS in your surgical practice and how to begin doing so.
What options do surgeons have for laser platforms when performing FLACS?
In 2010, femtosecond lasers became commercially available for use in cataract surgery in the USA. Cataract surgeons today have a large armamentarium of femtosecond laser platforms that they can utilize for FLACS cases.
The five currently available laser platforms include:
- Catalys (Johnson & Johnson, NJ, USA)
- Femto LDV Z8 (Ziemer Ophthalmic Systems, AG, Switzerland)
- LensAR (LensAR Inc, Orlando, FL, USA)
- Lensx (Alcon Laboratories Inc., Forth Worth, TX, USA)
- Victus (Bausch & Lomb, Rochester, NY, USA)
The key differences among femtosecond laser-assisted cataract surgery platforms
| Name of laser platform | Type of imaging | Interface |
|---|---|---|
| Catalys | 3D spectral domain OCT | Non-contact, liquid optics |
| Femto LDV Z8 | 3D spectral domain OCT | Non-contact, liquid optics |
| LensAR | 3D ray-tracing confocal structural illumination (CSI) with Scheimpflug technology | Non-contact, liquid optics |
| Lensx | 3D spectral domain OCT | Contact applanation |
| Victus | 3D spectral domain OCT | Contact applanation |
In general, non-contact, liquid optics interfaces only contact the sclera and conjunctiva, create a vacuum seal around the limbus, and minimize corneal distortions. They are also associated with less risk of subconjunctival hemorrhage as well as intraocular pressure rise.
Contact applanating interfaces used a curved contact lens and limbal suction ring to contact the eye and visualize the anterior segment. Improvements in contact interfaces have resulted in less corneal distortion and suction losses; yet there is often higher intraocular pressure rise with vacuum and subconjunctival hemorrhage formation with these platforms.
Despite the differing types of interfaces, femtosecond lasers allow the surgeon to obtain real-time, advanced, high-resolution optical coherence tomography (OCT) images of the entire anterior segment. Each laser has a different but user-friendly graphical interface that the surgeon can easily navigate to plan the different stages of the FLACS procedure.
Personally, I have the most experience with the Catalys and Lensx laser platforms and find both to be excellent to use for my FLACS cases.
Here is a video of how the Catalys femtosecond laser platform and graphical user interface is being used to plan the treatment for a patient undergoing FLACS.
Who are good FLACS candidates and how do you approach patient communication?
When discussing the role of FLACS in cataract surgery, I make a point to offer this technology to every patient I see if they are a good candidate. If they are a poor candidate for FLACS (i.e., presence of corneal opacities or conjunctival blebs, inadequate pupillary dilation, small palpebral fissures, inability to lay flat or a highly anxious personality), I explain why this technology would not be applicable or what challenges using it may pose for their surgical case.
The last thing you want is a patient to return to your clinic and question why all options that may have been presented to their friends or family members were not presented to them.
When speaking with patients, it’s critical to describe how FLACS differs from manual cataract surgery.
My typical patient script when discussing FLACS often sounds like this:
“We can perform cataract surgery in one of two ways. We can use the manual approach where we use blades to create incisions and enter the eye to remove the cataract. Or, we can employ the femtosecond laser, a technology that helps me as the surgeon perform key steps of the procedure and adds an additional layer of safety and precision to your surgery.
The laser helps me create a perfectly round opening to remove the cataract and insert your new lens, create incisions on the cornea to enter the eye as well as to correct astigmatism, which will ultimately help you achieve the best possible visual acuity. And, lastly, break up and soften the cataract so that I use less energy inside your eye and time when performing your surgery.
The femtosecond laser is a technology I like to implement for all my patients if they are good candidates, but it is not covered by insurance. After our meeting today, my coordinators can walk you through pricing if you are interested in using it during your surgery.”
The FLACS learning curve
Video or pictorial aids can help patients understand how the femtosecond laser will help the surgeon perform these key steps of the cataract surgery procedure:
- Create arcuate incisions on the cornea to correct astigmatism.
- Create a perfectly round capsulotomy.
- Perform lens fragmentation and/or softening to assist with nuclear disassembly.
- Create clear corneal incisions.
My surgical video of a femtosecond laser-assisted cataract surgery
This is a case of a patient who developed a visually significant cataract after a pars plana vitrectomy. The surgical video displays the key steps of the cataract surgery after creating a capsulotomy, arcuate incisions, and lens fragmentation with the Lensx femtosecond laser.
The pre-cut capsulorhexis can be easily removed with Uttrata forceps. A sextant pattern with five central cylinders was used to fragment and soften the lens nucleus. A stop-and-chop technique was then used to emulsify the nuclear material. Cortical material was carefully removed and a one-piece intraocular lens was placed in the capsular bag.
When it comes to patients choosing premium lens implants (i.e., toric, trifocal, extended depth of focus lenses), I focus on the importance of FLACS in helping address visually significant astigmatism for best uncorrected visual quality, in standardizing the capsulotomy size and centration as well as assisting with nucleus and cortical removal. I like to pair my premium lens implants with the femtosecond laser technology.
During surgical counseling, it is important for the surgeon to inform the patient that the use of the femtosecond laser is not covered by insurance—you never want this fact to be a surprise for patients as they can walk away with a bitter taste in their mouths. Based on your practice model, either the surgeon or the surgical coordinator can discuss the associated out-of-pocket pricing, payment policies as well as available payment plans.
My surgical workflow for femtosecond laser-assisted cataract surgery
Incorporating FLACS in your surgical workflow can be done in a straightforward manner.
First off, ensure that the surgical center(s) you operate in have a femtosecond laser platform. Work with an industry laser representative to train and grow comfortable with the laser platform if you have not utilized it before. Some companies will allow you to offer free access to the laser for your first 5 to 10 patients which can help with patient recruitment and utilization.
Understand how to utilize nomograms to calculate length and location of limbal arcuate incisions for precise astigmatism correction. Some commonly used nomograms include the Donnenfeld or Nichamin nomograms on www.lricalculator.com or the Wortz-Gupta formula on www.lricalc.com. For your first several cases, ensure that patients are calm-natured and willing to undergo FLACS. It’s important to choose patients with adequate pupillary dilation and moderate density cataracts. Like with any new procedure, you set yourself up for success by avoiding complex cases in order to maximize visual outcomes and therefore patient happiness.
I always found it valuable to watch videos of other surgeons performing FLACS cases to observe nuances in surgical technique.
As you perform your first handful of cases, work closely with the laser trainer to customize your settings to ensure you can operate effectively and efficiently.
I specifically suggest watching videos and reading up on the following important topics.
How to:
- Open clear corneal incisions
- Ensure a capsulotomy is complete and free-floating without tags
- Proceed with hydrodissection and nuclear disassembly
- Open limbal relaxing incisions intra-operatively or post-operatively in the clinic
- Approach cortical removal (since cortical material is often more adherent and challenging to remove in FLACS cases)
Slow down to speed up!
Initially, incorporating FLACS may slow down your operating room day as you learn to navigate the laser interface and perform intra-operative cases. However, once you feel comfortable with straightforward cases, you can advance to more complex cases in which FLACS can benefit the patient.
When considering complex cataract cases, I have often implemented FLACS for patients with white cataracts or hypermature cataracts with shallow anterior chambers, dislocated crystalline lenses, corneal scars, or previous implantable collamer lenses in whom manual capsulotomy creation can be challenging and nuclear disassembly can be difficult due to poor visualization, underlying zonulopathy, and high phaco energy use. In many scenarios, femtosecond laser use in such cases has added an additional layer of security and made these cases far more routine and easier to manage.
Integrating FLACS in summary
In conclusion, surgeons can seamlessly integrate FLACS into their surgical practices. FLACS conversion in practices can steadily increase as surgeons and their staff become better acquainted with the benefits of this technology.
In an era where reimbursement for cataract surgery is declining, this technology can offer ophthalmology practices new opportunities to develop a thriving refractive cataract surgery practice. Frequency and quality of software updates for many laser platforms has increased the efficiency and speed of FLACS and overall lower costs to acquire femtosecond lasers has helped with FLACS adoption.
Ultimately, this technology can offer many benefits for both patients and surgeons alike and can be an excellent tool to incorporate into a surgeon’s refractive cataract surgery armamentarium. The technology, while initially a financial investment for a practice, can prove to provide both monetary and visual outcome benefits for patients and surgeons alike.
