The Future of FLACS

Looking at the past and present to determine the future of femtosecond laser-assisted cataract surgery

Boris Malyugin

Posted: Tuesday, May 1, 2018

The history of cataract surgery for centuries was spinning around two main issues – increased safety and improved efficiency. The first things that come to mind when we are talking about lasers in any field of medicine, including surgical procedures, are exactly those two already mentioned – namely safety and efficiency. They are achieved by high precision of laser energy applications combined with minimal collateral tissue damage along with the possibility to choose the wavelengths selectively interacting with the target tissue, whether it is cornea, lens material, ciliary body, vitreous, retina or any other. One of the most significant features of many laser procedures is the ability to treat ocular tissues without actually opening the eye globe.

Starting with retinal detachment and followed by glaucoma and secondary cataract treatments, lasers become the integral part of ophthalmology’s standard armamentarium. In 2008 the new page of cataract surgery was started with the introduction of the femtosecond lasers now known as FLACS (femtosecond laser-assisted cataract surgery). Ten years later we can turn back and reflect on where are we now and where are we heading with that technology?

During these years hundreds of thousands of patients were treated with FLACS. The data collected up to date showed that overall results are more or less similar to those achieved with the standard cataract procedures. That is more or less true for uncomplicated cataract surgery. However, when we are talking about complicated cataracts, things look very different.

FLACS has shown to be beneficial in patients with low endothelial cell counts, unstable zonules, displaced and subluxed lenses. Precise capsulotomy achieved with laser energy applications is considered to be good for paediatric cases, as well as the eyes when posterior capsulorhexis is indicated for any reason. Intraocular lenses specifically designed for FLACS are based on the fact that this technology may provide the precision of positioning and sizing the capsulorhexis that cannot be achieved with manual techniques.

Moreover, femtosecond lasers have proven useful when an IOL has to be removed from the eye for some reason. In these cases, either a pseudophakic or a phakic lens is cut prior to explantation in order to reduce the surgical trauma. The whole spectrum of FLACS applications in complicated cataract cases is currently expanding, presenting new horizons for that technology. However, in most cases it is a bit early to make the final judgments.

From the technical standpoint, I do strongly believe that FLACS has still a lot of room for improvement. These devices should one day become truly portable and compact; the necessity to move the patient from one step to another should be excluded. I am not talking today about the financial side of the FLACS story, but there is definitely room for improvement there as well.

In summary, 10 years past the first steps taken we are still climbing and have not yet reached the summit. The good news is that we can already see the top, at least some parts of it, and that gives us hope of conquering that hill one day.