Does FLACS cost, benefit outweigh manual? Yes!

Reviewed by Robert J. Cionni, MD

Though further study is needed to determine conclusively whether or not femtosecond laser-assisted cataract surgery (FLACS) is associated with better refractive outcomes compared with conventional manual surgery, FLACS offers many other benefits that justify its use, according to Robert J. Cionni, MD.

“There have been numerous peer-reviewed studies and meta-analyses that failed to demonstrate refractive outcome superiority for FLACS compared with conventional cataract surgery,” said Dr. Cionni, medical director, The Eye Institute of Utah, Salt Lake City.

On the other hand, some studies demonstrated better results for FLACS in terms of quicker recovery, better refractive stability, fewer higher-order aberrations, and even in hitting the refractive target, he noted.

“There is no evidence that the refractive result is worse after FLACS, while there is evidence that FLACS creates a more precise capsulotomy, reduces ultrasound energy usage, postoperative corneal edema, and corneal endothelial cell loss,” Dr. Cionni said.

“Furthermore, FLACS does not increase the overall incidence of complications, it may be associated with a lower rate of vitreous loss, and it is immensely helpful in challenging cases, including eyes with posterior polar, brunescent or white tumescent cataract, as well as those with zonulopathy, where it can allow safe capsulotomy and reduce the need for ultrasound energy,” he added.
 

Speaking from experience

As a proponent for FLACS, Dr. Cionni speaks based on substantial experience. In February 2011, the first commercially available femtosecond laser installation occurred at The Eye Institute of Utah, and as of October 2016, Dr. Cionni had performed more than 2,600 FLACS procedures, counting only routine and premium cases but not more difficult, complex cases.

“FLACS now represents 35% of all of my cataract cases, and data from Market Scope and Alcon Laboratories show it has been growing worldwide,” he said.

Flawed research

Flawed research

Discussing the discrepancy in the findings of comparative studies investigating refractive outcomes of FLACS and conventional cataract surgery, Dr. Cionni pointed out that the result is only as good as the weakest link, and there are two weak points that persist.

The first has to do with IOL power, which is available in steps of just 0.5 D for most implants and may vary by 0.17D from the labeled value. However, the fact that true effective lens position (ELP) remains unknown is the bigger issue.

“Even using FLACS and with intraoperative aberrometry, the noise that is introduced into the IOL calculation by estimating ELP is simply too great to demonstrate superiority of one technique versus another,” said Dr. Cionni, adding that the A constant for FLACS cases will differ and also needs to be optimized when investigators are comparing refractive outcomes of the two techniques.

Refractive benefits of FLACS

Suggesting that a contralateral eye-controlled design is best suited for comparing FLACS and manual cataract surgery because it eliminates confounding from estimating ELP, Dr. Cionni cited the results of one study that found better outcomes with FLACS [Conrad-Hengerer I, et al. J Cataract Refract Surg. 2015;41:1356-1364].

In that study including 100 patients, the refractive outcome was within 0.5 D of target in 92% of FLACS eyes but in only 71% of conventional cases.

In addition, FLACS was associated with earlier refractive stability compared with manual cataract surgery (1 week versus 1 month).

Dr. Cionni also reviewed evidence to support the idea that FLACS has advantages for achieving more predictable results when correcting astigmatism, using either an incisional technique or a toric IOL.

The difference reflects the increased precision of the laser versus a manual technique for creating arcuate incisions and the capsulotomy, Dr. Cionni said.

“The precision of the laser-created arcuate incisions in terms of depth and position is better than what can be achieved manually,” Dr. Cionni said. “In addition, numerous studies show that even overlap of the capsulotomy rim over the IOL optic should result in less tilt for a toric IOL, and the benefit of less tilt will be particularly important when implanting a higher-power toric IOL.

“As we recently reported in a published paper [Woodcock MG, et al. J Cataract Refract Surg. 2016;42:817-825], 90% of eyes undergoing toric IOL implantation had less than 0.5 D of residual astigmatism when the procedure combined FLACS with intraoperative aberrometry and other best methods for choosing toric IOL magnitude and alignment,” he said.

Cost and time issues

Cost and time issues

Addressing economic issues, Dr. Cionni said that the cost of FLACS is fully supported by self-pay. Many patients have the means and willingness to pay for a FLACS procedure. The fees they pay out of pocket support the extra cost of the laser that is incurred by the surgery center and that compensates for the extra time spent by surgeons when they perform FLACS.

Robert J. Cionni, MD

E: rcionni@theeyeinstitute.com

This article was adapted from Dr. Cionni’s presentation at the 2016 meeting of the American Academy of Ophthalmology. Dr. Cionni is a consultant to Alcon Laboratories and Johnson & Johnson Vision.