Optimising cataract surgery outcomes

New technology for cataract surgery prevails when it provides clear advantages

Cheryl Guttman Krader

Posted: Wednesday, March 22, 2017

Zoltan Z Nagy MD

Statistically significant differences favoring use of a femtosecond laser versus conventional cataract surgery techniques have been reported for a variety of endpoints analysed in comparative clinical trials. The role of femtosecond laser-assisted cataract surgery (FLACS) remains controversial, however, as some surgeons believe there is a need for more evidence to prove that the advantages of FLACS justify its added cost, according to  Zoltan Z Nagy MD.

“We have seen before that new technology for cataract surgery prevails when it provides clear advantages, even if it is more expensive, and the femtosecond laser provides numerous potential benefits,” said Dr Nagy, Budapest, Hungary.

Discussing the advantages of FLACS, Dr Nagy reviewed data from his own studies demonstrating that compared with use of a manual technique, capsulotomy performed with the femtosecond laser resulted in better IOL capsular overlap, better IOL centration, reduced IOL tilt, more predictable effective lens position, less higher order aberrations, and better optical quality.

Use of the femtosecond laser for lens fragmentation reduced ultrasound energy use, corneal edema, and macular thickening. Use of the laser for corneal incisions assures perfect geometry, and it provides an opportunity to correct preoperative corneal astigmatism, Dr Nagy said.

Furthermore, use of the femtosecond laser enables cataract surgery in various challenging situations, and brings potential for practice building considering surgeons performing FLACS still face limited competition for attracting today’s population of cataract surgery patients who are attracted by procedures involving state-of-the-art technology.

We have seen before that new technology for cataract surgery prevails when it provides clear advantages

Negatives and unknowns

Dr Nagy acknowledged that the many of the benefits of using the femtosecond laser for capsulotomy may be mostly relevant to cases involving multifocal IOLs. And, he admitted that excellent outcomes can also be achieved using a manual technique. However, predictability for achieving a perfect capsulotomy is poorer with a manual approach, especially considering that multifocal IOL cases generally involve younger patients who refuse anything more than topical anesthesia and so have a tendency to move.

Problems that have been reported with FLACS include suction breaks, conjunctival redness, and capsular blockage syndrome along with increased rates of anterior capsule tears, intraoperative miosis, and corneal endothelial loss. Dr Nagy suggested, however, that some of these issues are learning curve-related and others have been addressed by hardware improvements and modifications in surgical technique.

Still, more time is needed to determine whether FLACS is safer overall than traditional phacoemulsification and if it is associated with less posterior capsule opacification (PCO), Dr Nagy said.

“The effect of FLACS on PCO is debated in the literature. Experience in our series suggests the rate of PCO is lower after FLACS, but there is some opacity under the laser cut. Therefore, we need a few more years of follow-up,” he stated.


Zoltan Z. Nagy, MD