How successful is laser assisted Cataract Surgery? And what is femtosecond laser assisted Cataract Surgery (FLACS)? Femtosecond laser assisted Cataract Surgery (FLACS) utilizes an amazingly precise laser to perform the most technically demanding steps of modern cataract surgery. It allows extreme reproducibly and  duceability results with a computer-guided laser linked to an optical imaging system called optical coherence tomography (OCT) to perform microscopically precise corneal incisions; capsulotomy- which is where a thin membrane is delicately peeled away in a circular fashion on the surface of the cataract, and lens fragmentation- in which the lens of our eye is liquefied and suctioned out of our eye through a microscopic incision. This has been performed with a phacoemulsification device for the past 50 years. The phacoemulsification instrument is still still used, but FLACS reduces the energy in the eye and therefore is safer and causes less inflammation with quicker healing times. Although experienced surgeons have been performing these delicate tasks very reproducibly for decades, nothing is quite as precise and reproducible as a laser that is trained to do whatever exact incision is programmed.

Understanding the Basic Shape and Anatomy of the Lens of our Eyes

Imagine a plain chocolate M&M candy. Now imagine it suspended from fibers, extending like the springs of a trampoline so that the M&M candy is the part that you jump on in a trampoline. These springs or fibers are attached to the circular periphery of your eye, just behind your iris (the colored part of your eye) so you can’t see the lens. This lens gets less flexible in our 40s to the point where we need reading glasses or some other solution. This is called presbyopia.

In our 60s and 70s, the lens of our eyes gets not only inflexible but becomes increasingly cloudy to the point where light entering our eye is scattered, which causes glare, halos, reduced contrast sensitivity, and reduced clarity of vision. At some point in the decline of the lens, we decide to have cataract surgery. Cataract surgery is where we remove that natural lens and replace it with an artificial lens.

A Brief History of FLACS

The application of ultra short laser pulses to the cataract tissue was first proposed in 1992. By ultrashort we mean that each pulse of the femtosecond laser is 1 millionth of a billionth of a second. Now that is indeed short! The lasers can be programmed to virtually any shape desired. Much of that flexibility is used by the surgeon to make exactly the size and shape of incisions desired. The lasers were tested and perfected over many years. It took quite some time to prove to the FDA that they were safe and effective. There still is no evidence that outcomes are better, but the ease and precision for surgeons makes it extremely appealing and makes the technical aspects of surgery easier.

The first FDA approved laser approved for FLACS was Alcon’s LensEx in 2011 followed shortly thereafter by lasers from J&J and Ziemer. Since 2011, there have been many improvements in the interface, the precision of the imaging, and the speed of the lasers.

Brands of FLACS Lasers

LensEx by Alcon

Catalys by Johnson & Johnson

Z8 by Ziemer

Each of these lasers is superb, and there are very few problems. Surgeons who have used all three platforms generally are very comfortable with each of the three.

How Does the Patient Experience Change with FLACS?

With laser assisted Cataract Surgery, the patient is placed on the operating room table, then we attach EKG electrodes, a small clip that fits on the index finger to monitor blood oxygenation called a pulse oximeter, and an automatic blood pressure cuff to measure blood pressure. There are no needles. There are no blades. The operative eye is prepped with a cleaning solution and draped with a sterile surgical drape. The patient experience is of a bright light. Our patients are given medication to relax them so they can lie comfortably for the 10 minutes per eye. The procedure is utterly painless.

What is the Femtosecond Laser Doing During the Procedure?

With FLACS, the patient lies flat with their head firmly secured in an evacuated pillow or other method of stabilizing their head. They typically will feel pressure as the laser interface holds their eye with a light suction. The device then scans the structures of their eyes with optical coherence tomography (OCT) that allows a fantastic microscopic visualization of the structures of their eyes. The laser itself takes anywhere from 20 to 60 seconds to perform the 3 to 4 tasks:

1. Capsulotomy: The laser cuts a perfect 5 mm circle on the surface of the lens (think of this as cutting the “shell” of the M&M candy).
2.  Lens Fragmentation: Think of this as removing the chocolate from the M&M candy. This can be done in an “ice cube tray“ pattern to cut the lens into tiny cubes, a “pie shaped“ pattern, or just four equal segments like an aspirin pill.
3. Limbal Relaxing Incision (LRI): For patients with astigmatism. If you don’t have astigmatism, your surgeon will skip this step.
4. Incisions: Generally, there are two incisions: the main incision and paracentesis. The main incision is made at the outer edge of the cornea and is usually between 2.5 and 3.5 mm. There is also a paracentesis incision made about 30-45 degrees away. The paracentesis is even smaller and is used for a second instrument for the surgeon to control, move, and extract the pieces of the cataract.

Benefits of FLACS

The visual outcomes with the FLACS is the same whether the procedure is performed manually or with the assistance of a laser. As a surgeon, I prefer performing laser assisted Cataract Surgery, if possible, because it makes the precision greater than anything I could do manually. It also decreases the inflammation in the eye and potentially allows quicker healing times. Patients who have uncomplicated cataract surgery generally heal extremely quickly anyway. This laser precision may be slightly more important for modern intraocular lenses to be perfectly centered and give us a reproducible outcome that simply can’t be matched with manual surgery.

Risks and Safety of FLACS

Modern Cataract and Refractive Lens Exchange (RLE) is the most commonly performed surgery in the United States, with over 4 million people having cataract surgery every year. The vast vast majority of these go perfectly. As with any procedure though, the unexpected complication can and does happen infrequently. It’s important for you to understand these risks and compare them to the benefits to make the best medical decision for yourself. Your surgeon can help you understand which complications are the most common in general and if there are any complications that are more likely for you due to some anatomical or other related health condition. FLACS makes the procedure just a bit more precise and therefore safer and more predictable. With FLACS, the laser pre-cuts everything for the surgeon, so it’s easier to extract the lens material. The surgery itself takes anywhere from 4 to 15 minutes. Cataract surgery is painless; you’re awake but nicely relaxed, warm, and comfy during the procedure. Your surgeon can talk to you to let you know how much longer the surgery will take and how it’s going. And it’s usually going perfectly.

At SharpeVision Modern Lasik & Lens, our Cataract/RLE surgeons Dr. Nick Lancaster, MD (Austin) and Dr. Luke Barker, MD (Seattle) are simply the best. They each have over 10 years of experience performing cataracts, using cutting edge techniques and technology including multifocal intraocular lens implants like Vivity and Panoptix. At the new SharpeVision Modern Lasik & Lens refractive center in Bellevue, WA, we have the Alcon Ngenuity 3-D imaging system to perform laser assisted cataract surgery. We open in December 2022. We are very excited!

Come get your free comprehensive Refractive Surgery evaluation. Schedule online at sharpe-vision.com or call us at 425-451-2020. We look forward to helping you live your best life seeing clearly without glasses or contact lenses.