LACS vs Manual Cataract Surgery

New technology can improve some surgeries, but manual may be more efficient. Howard Larkin reports from ASCRS in Las Vegas, USA.

Howard Larkin

Posted: Friday, October 1, 2021

New technology can improve some surgeries, but manual may be more efficient. Howard Larkin reports from ASCRS in Las Vegas, USA.

Two busy surgeons made a case for laser-assisted cataract surgery (LACS) or conventional manual cataract surgery in a spirited debate at this year’s conference.

Making a case for LACS, John J DeStafeno MD argued that extracapsular manual surgery is excellent, but the key to improving cataract surgery is embracing new technology.

“Where would we be right now if we didn’t embrace developments in intraocular lenses? Pharmacology? Corrective lenses? LASIK? Phacoemulsification?” Dr DeStafeno asked.

When discussing LACS, surgeons often ask if it makes cataract surgery any safer or quicker, or if it promotes better healing, reduces endothelial cell loss, or provides better vision, he explained.

“The key when you are looking at new technology for your practice is do you think it makes you a better surgeon, is it something you want to have in your toolbox?”

For Dr DeStafeno, the answer is yes. “I like it for small pupils, pseudoexfoliation, [reducing] phaco energy, deeper orbits, and corneal diseases like Fuch’s dystrophy and patients with retinal issues.”

LACS allows him to do more with less, Dr DeStafeno said. “I can use less trypan blue, fewer blade-based LRIs. I can do it all in one.”

That includes capsulorhexis, lens fragmentation, surgical wounds, arcuate incisions, and even marks on the cornea or capsule for aligning toric lenses more accurately. LACS can reduce long-term complications like phimosis from working in a small capsulorhexis. It also helps avoid the risk of iris expansion rings, reduce corneal oedema, and avoid TASS by not injecting dyes, he said.


Concerns about LACS include not enough volume to support a machine purchase and expensive disposables for a procedure not covered by insurance. Some surgeons also do not treat astigmatism and fear increased complications—though Dr DeStafeno said he has experienced very few complications with LACS.

Dr DeStafeno outlined a few ideas for making LACS financially viable. One is to lease lasers. “They have roll-on, roll-off; they have great lease packages with very affordable minimums.”

An alternative way to decrease the LACS cost burden is by incorporating the technology into premium services. “Offer LACS to presbyopia-correcting or toric IOL patients. Insurance also does not cover preoperative-screening OCTs, topography, wavefront aberrometry, etc., and practices do charge for theseservices,” Dr DeStafeno said. “You can also add free laser enhancements and extended postop care.”

But the bottom line is technology can make surgery better, Dr DeStafeno said. “Don’t struggle with that deep orbit. Don’t struggle [by] looking through a fishbowl all the time. … Expand your toolbox. Be part of making it better, just like we did with phaco. Embrace technology. Make it work for you,” he urged delegates.


Arguing for manual surgery was R Luke Rebenitsch MD.

“I like to make things simple,” he said.

He cited a study by the ESCRS involving 16 centres in 10 countries and more than 2,800 surgeries that found no improvement in either visual or safety results for LACS over manual surgery. Posterior capsule complications, absolute biometry prediction error, and postoperative complications were all equivalent.

“If anything, there was a trend toward worse distance corrected vision. Maybe that’s from the prostaglandin release. Another study found little difference in capsulorhexis strength.”

Endothelial cell loss may be slightly less in LACS, averaging 55.43 cells per mm2 more cells compared with manual surgery in one large meta-analysis, Dr Rebenitsch allowed. “Is it clinically relevant? Probably not for most cases.”

Concerning cost, a French Ministry of Health study involving 1,476 eyes in 907 patients found equivalent outcomes between FLACS and manual surgery with €10,703 saved per manual patient (Lancet 2020; 395: 212–224).

In his own practice, Dr Rebenitsch had a laser break down after more than 1,000 laser cases, forcing a return to manual surgery.

“What I found was we were doing one less eye per hour with femto.”

A little more anaesthesia and pretreatment with NSAIDs also were required for femto.

“So, I just thought, ‘are we throwing away time? Time is money.’ We’re paying for the laser and we’re losing time,” Dr Rebenitsch said.

Better ways to improve safety include using augmented reality microscopes, dispersive OVD, phaco-choppers, non-longitudinal ultrasound, and glutathione-enriched irrigation, Dr Rebenitsch said. Manual surgery is more efficient and decreases the cost for equivalent outcomes, he concluded.

John J DeStafeno MD is a cataract and corneal specialist at Chester County Eye Associates, West Chester, Pennsylvania, USA and clinical instructor at Wills Eye Hospital, Philadelphia, USA

R Luke Rebenitsch MD has an ophthalmologist practice in Oklahoma City, USA

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