This article is more than 5 years old. Information may no longer be current.
Femtosecond laser-assisted cataract surgery represents new frontier
Click Here to Manage Email Alerts
Femtosecond laser-assisted cataract surgery, or FLACS, represents a new frontier in cataract surgery. This technology is relatively new, and therefore “teething problems” are inevitable. Since its introduction in 2008, a lot of enhancements have been achieved. To further the discussion from the last issue, optimization of the procedure is the theme of this month’s cover story.
Currently, most surgeons perform FLACS on their patients in a room independent from the cataract operating theater. Collaborating with another surgeon who will focus on performing the femtosecond laser procedure is suggested for higher-volume surgeons. Collaborations shorten the surgery time, but if laser surgery is done by a different surgeon, a standardized protocol is very much needed. Acceptance by patients is also an issue of concern. In our practice, the same doctor performs both procedures. The femtosecond laser procedure takes around 5 minutes if the patient has been fully prepared. Once the femtosecond procedure is finished, we let the patient take a 15-minute rest before cataract surgery, and another phaco surgery is arranged in between. The overall efficiency of such an arrangement is very reasonable.
One main concern of current FLACS is pupil constriction. The cause of constriction has yet to be fully elucidated. It may relate to mechanical factors, such as laser energy, or chemical factors, such as lens particles; the role of inflammation is also suspected. To defeat miosis, preoperative topical NSAIDs and steroid eye drops can be considered; simply adding supplementary mydriatic eye drops is also a good choice. In our practice, the constriction after femto procedures is not a problem most of the time. The time between femtosecond laser procedures has been raised as an affecting factor. It is claimed that a time delay between femtosecond laser and phaco should be as short as possible to give the eye less time to react and therefore avoid constriction of the pupil caused by inflammatory stimulation inside the eye.
In the beginning, complex cases were contraindications for FLACS. The trend, however, has shifted, and FLACS is now considered favorably by many surgeons to take care of complex cases. We have applied this new technology to difficult cataract surgeries, including hard nucleus, shallow anterior chamber, zonular weakness, ectopia lentis and posterior polar cataract, with good results.
It has been reported that more than 50% of FLACS cases have unsightly subconjunctival hemorrhage. Reducing and preventing the occurrence of subconjunctival hemorrhage will certainly increase patient satisfaction. We use a topical antihistamine (vasoconstrictor) and 10% epinephrine (for a patient without hypertension) as preoperative medications. A significant reduction of the subconjunctival hemorrhage rate has been achieved.
Other issues, such as increasing intraoperative corneal haze, centration of the capsulorrhexis, tilting of the eyeball and the nomogram for astigmatic keratotomy, are areas that need further enhancement. It is hoped that most of the above issues will be addressed with good solutions in the future. However, we do need more studies for this new procedure.
Disclosure: Lam and Liang have no relevant financial disclosures.