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https://doi.org/10.1177/1120672120922448
European Journal of Ophthalmology
1 –10
© The Author(s) 2020
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DOI: 10.1177/1120672120922448
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EJO European
Journal of
Ophthalmology
Introduction
Femtosecond lasers emit ultrashort high-power pulses at
infrared wavelength (1053 nm) which induces photodis-
ruption or photoionization of biological tissues.1 In oph-
thalmology, femtosecond lasers were first employed for
corneal surgery. Their introduction to cataract surgery
dates to 2008;2 a higher precision of capsulorrhexis and
reduced phacoemulsification power was reported both in
porcine and in human eyes.3 Since the inauguration, fem-
tosecond lasers were supposed to eliminate the problems
associated with ultrasonic waves and revolutionize cata-
ract surgery. Despite these hopes, the judgment of clinical
benefits was found to be far more complex than might
have been primarily thought. A recent analysis revealed no
substantial differences between femtosecond laser-assisted
cataract surgery (FLACS) and conventional phacoemulsi-
fication cataract surgery (PCS) concerning visual or refrac-
tive outcomes as well as the reported complication rates.4
FLACS manifested benefits in terms of certain surgical
parameters including decreased cumulative dissipated
The benefits and drawbacks of
femtosecond laser-assisted
cataract surgery
Piotr Kanclerz1 and Jorge L Alio2,3
Abstract
Introduction: Since the introduction, femtosecond laser-assisted cataract surgery was believed to revolutionize
cataract surgery. However, the judgment of clinical benefit was found to be far more complex than initially might have
been thought. The aim of this review was to analyze the benefits and drawbacks of femtosecond laser-assisted cataract
surgery compared with traditional phacoemulsification cataract surgery.
Methods: PubMed and the Web of Science were used to search the medical literature. The following keywords were
searched in various combinations: femtosecond laser, femtosecond laser-assisted cataract surgery, phacoemulsification cataract
surgery, FLACS.
Results: The benefits of femtosecond laser-assisted cataract surgery include lower cumulated phacoemulsification time
and endothelial cell loss, perfect centration of the capsulotomy, and opportunity to perform precise femtosecond-
assisted arcuate keratotomy incisions. The major disadvantages of femtosecond laser-assisted cataract surgery are high
cost of the laser and the disposables for surgery, femtosecond laser-assisted cataract surgery–specific intraoperative
capsular complications, as well as the risk of intraoperative miosis and the learning curve.
Conclusion: Femtosecond laser-assisted cataract surgery seems to be beneficial in some groups of patients, that is,
with low baseline endothelial cell count, or those planning to receive multifocal intraocular lens. Nevertheless, having
considered that the advantages of femtosecond laser-assisted cataract surgery might not be clear in every routine case,
it cannot be considered as cost-effective.
Keywords
Cataract surgery, corneal incisions, femtosecond laser-assisted cataract surgery, phacoemulsification, cost-effectiveness
of surgical procedures, cataract surgery complications
Date received: 13 January 2020; accepted: 2 April 2020
1Hygeia Clinic, Gdańsk, Poland
2Vissum Instituto Oftalmologico de Alicante, Alicante, Spain
3
Division of Ophthalmology, Universidad Miguel Hernández, Alicante,
Spain
Corresponding author:
Jorge L Alio, Vissum Instituto Oftalmológico de Alicante, Avda De
Denia s/n, Edificio VISSUM, 03016 Alicante, Spain.
Email: jlalio@vissum.com
922448EJO0010.1177/1120672120922448European Journal of OphthalmologyKanclerz and Alio
research-article2020
Original Research Article
2 European Journal of Ophthalmology 00(0)
phacoemulsification energy, better capsulotomy circular-
ity, reduced postoperative corneal edema, or corneal
endothelial cell loss. The aim of this study was to review
the benefits and drawbacks of FLACS compared with tra-
ditional PCS.
Methods
PubMed and the Web of Science were the resources
employed to search the medical literature. A comprehen-
sive search was performed to identify the clinical applica-
tions and outcomes of FLACS in human eyes as reported
up to 15 June 2019. The following keywords were used in
various combinations: femtosecond laser, femtosecond
laser-assisted cataract surgery, phacoemulsification cata-
ract surgery, FLACS. The PubMed search used the expres-
sion (((“femtosecond laser”[Title]) AND (“cataract
surgery”[Title])) OR (“femtosecond laser-assisted cata-
ract surgery”[Title]) OR (“FLACS”[Title])) and found 336
references. The Web Of Science search used the expression
(TI=(femtosecond laser) AND TI=(cataract surgery)) OR
TI=(femtosecond laser-assisted cataract surgery) OR
TI=(FLACS) Indexes=SCI-EXPANDED, SSCI, A&HCI,
CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH, ESCI, CCR-
EXPANDED, IC and found 410 references. After removing
duplicates, 428 references were screened. Only articles
having English-language abstracts were included. The ref-
erence lists of identified publications were also included as
potential sources of relevant articles. Studies were critically
reviewed to give an overview and provide guidance for fur-
ther investigation. No efforts to discover unpublished data
were made. In addition to the search, selected chapters
from relevant textbooks and trials registered in the
ClinicalTrials.gov were included, if necessary. Emphasis
was placed on articles published since the review by
Hooshmand and Vote,5 but we included earlier articles in
order to provide a more comprehensive view.
An overview of intraoperative
benefits and drawbacks of FLACS
The overview of intraoperative complications in FLACS and
PCS based on large cohort studies is presented in Table 1.
Some difficulties including anterior radial tears, anterior
capsule tags, or suction break during the procedure could
be considered as FLACS specific. According to Roberts
et al.,6 the rate of complications in FLACS decreases with
surgical experience, that is, the reported incidence rate of
capsular tags was 10.5% in the surgeon’s first 200 cases,
while only 1.6% in the next 1300 cases.
Complications associated with laser docking
Femtosecond laser platforms may employ different patient
interface designs: a curved contact lens or liquid optical
interface.10 In applanating platforms vacuum is applied for
suction cup placement. Although the vacuum levels are
lower compared with those in manual microkeratomes, the
time needed to perform the FLACS procedure is signifi-
cantly longer.11 During the docking, due to applanation
and strong deformation of the eye, an intraocular pressure
(IOP) elevation over 90 mmHg above baseline can be
observed.12 The IOP rise in course of applanation is higher
with curved contact lens interfaces than with a liquid opti-
cal immersion interface.10 Some authors believe that ante-
rior movement of the vitreous base during suction could
presumably provoke development of vitreoretinal pathol-
ogy.13 There is no clear evidence that high IOP associated
with the application of the suction ring is harmful; how-
ever, such effect should be taken into account in more
Table 1. Prevalence of intraoperative complications in PCS and FLACS in selected cohort studies.
Method PCS FLACS
Study Syed et al.7
(n = 20,070)
Jaycock et al.8
(n = 55,567)
Roberts et al.6
(n = 1300)a
Manning et al.9
(n = 2814)
Anterior radial tears (%) N/A (FLACS specific) 0.31 0.5
Anterior capsule tags (%) 0.31 0.5b
Pupillary constriction (%) 1.23 N/A
Suction break/procedure abandoned (%) 0.61 0.1
Manual corneal incision (%) 1.92 0.9
Capsule bridges/incomplete capsulotomy (%) N/A 0.4
Posterior capsule rupture with or without vitreous loss (%) 0.53 1.92 0.31 0.4
IOL complications (decentration, explantation) (%) 0.05 0.01 0.00 N/A
Zonular dialysis (%) 0.10 0.46 N/A N/A
Dropped nucleus (%) N/A N/A N/A 0.1
Iris trauma/iris prolapse (%) N/A 0.55 N/A N/A
FLACS: femtosecond laser-assisted cataract surgery; N/A: not available; PCS: phacoemulsification cataract surgery; IOL: intraocular lens.
aAfter the first 200 cases.
bIncludes minor anterior capsule.
Kanclerz and Alio 3
fragile eyes with glaucomatous damage.14 Moreover, the
residual IOP after vacuum undocking is higher in glauco-
matous than in non-glaucomatous eyes, and glaucomatous
eyes have a more prominent transient IOP rise after treat-
ment.15 Another problem is that pressing the suction cup
against the cornea results in unwanted folds on its poste-
rior surface.16
A difficulty associated with using a suction cup is the
potential loss of suction and stoppage of the procedure. In
a study by Zhang et al.17 on Chinese patients, the comple-
tion rates of the laser capsulotomy, lens fragmentation, and
corneal incisions were 98.6% (95% confidence interval
(CI): 97.8%–99.1%), 99.5% (95% CI: 99.1%–99.8%), and
97.6% (95% CI: 96.7%–98.3%), respectively. In all cases,
the surgeons’ experience was high and the study had strict
patient selection criteria; it excluded individuals with a
small pupil, with corneal edema or dense corneal scars,
hyperopic patients, or those with steep corneas. In a
smaller series, the rate of incomplete capsulotomy was
0%–12%, while incomplete phacofragmentation was
noted in 4%–10% of cases.18 In a study by Bali et al.,19 the
average count of docking attempts was 1.8–1.9 in the first
100 cases, while 1.2 in the next 100 cases. In order to
decrease the risk of an incomplete capsulotomy or subcon-
junctival hemorrhage, a liquid optical immersion interface
or soft lens–assisted interface could be applied.10,18 On the
contrary, Manning et al.9 reported suction brake/FLACS
procedure abandoned only in 0.1% of cases. Finally, the
laser docking requires additional steps, introduces unique
risk associated with these steps, and is time-consuming.20
Corneal incisions
A well-constructed corneal incision facilitates cataract sur-
gery; it should allow wound sealing at the end of the proce-
dure. Although the femtosecond laser was used primarily
for lamellar corneal surgery, with time it was adapted to aid
performing the clear corneal incision in cataract surgery.21
Incisions performed with the femtosecond laser were found
to be reproducible and stable over time.22 Moreover, it is
possible to program the incision architecture; usually, a tri-
planar configuration is used for the main incision, while
side ports are created as uniplanar incisions. On the other
hand, morphological analysis of laser incision-specimens
revealed significantly higher count of apoptotic cells and
that the cutting edge in a femtosecond laser corneal speci-
men has a sawtooth-like pattern, when compared to manual
PCS in which the incisions are smoother.23
Recent optical coherence tomography studies reported
that although laser-constructed corneal incision are more
precisely performed and manifest similar healing com-
pared with a manual incision on postoperative day 30
(POD30), they present a slower anatomical improvement
than manual incision.24,25 Rodrigues et al.24 noted a partial
loss of wound sealing in virtually all triplanar wounds
created with the femtosecond laser on POD1, and in only
44.6% cases of manual incisions (p = 0.03). Moreover,
although femtosecond laser incisions were not submitted
to stromal hydration at the conclusion of surgery, they had
greater corneal thickness, an increased number of endothe-
lial gaps and Descemet detachments compared with man-
ual incisions.25 Presumably, these findings were associated
with greater surgical manipulation within the incision and
not the laser thermal damage.25
Another issue to be considered when comparing man-
ual and femtosecond-assisted corneal incisions is the
potential to perform arcuate keratotomy (AK), which can
be used in treating low-grade astigmatism during PCS. A
problem in manual AK incisions is a relatively low pre-
dictability due to the limited reproducibility in incision
length and axis alignment.26 Theoretically, an advantage of
femtosecond-assisted AK is the facility to perform, safety,
and greater reproducibility. However, misalignment of the
cylinder axis was also found to be a problem in femtosec-
ond-assisted AK; in a study by Chan et al.,27 the average
angle of error for AK was close to 0°; however, the abso-
lute angle of error was 17.5° ± 19.2°. In another study
evaluating AK for correcting low-to-medium astigmatism,
the mean correction index was 0.63 ± 0.32 (range: 0.0–
1.93), demonstrating that the average reduction in astig-
matism power was 63%.28
Capsulotomy
A substantial advantage of femtosecond laser capsulotomy
(FLC) is the possibility to create a perfectly positioned,
sized, and shaped capsulotomy.29,30 This benefit would
potentially be important in patients receiving multifocal
intraocular lenses (IOLs), where the IOL centration might
affect the visual performance. In a study by Panthier
et al.,31 the capsulotomy sizing was more precise in FLC
than in manual continuous curvilinear capsulorrhexis
(CCC). With that, the FLC size changed in a lesser extent
than for manual CCC in a 1-year observation period.
Nevertheless, FLC did not improve the effective lens posi-
tion or visual quality.
A problem with FLC is the strength of the capsular
edge, which was shown to decrease with increasing laser
energy levels.30,32 Even with optimized energy settings,
FLC presents lower stress resistance and higher propen-
sity for anterior radial tears compared with manual
CCC.33 An experimental study on human cadaver eyes
showed that the fracture strength of the FLC is lower than
in manual CCC by a factor of 1.28.34 Scanning electron
microscopy images revealed that the edge of the FLC
presents a saw-like pattern with nearly perpendicular,
frayed rims and numerous notches, in contrast to smooth
edge of a manual capsulotomy.33,35,36 Such irregularity
could be associated with skip lesions and aberrant mis-
fired pits, which could arise from minimal fixational eye
4 European Journal of Ophthalmology 00(0)
movements.37 As a consequence, clinically the rate of
anterior capsule tears is higher in FLC (1.84%) than in
manual CCC (0.22%).38 In other investigations, the rate
of anterior capsule tears in FLC ranged from 0.1% to
4.0%.39,40 In FLC, the use of angled bimanual irrigation/
aspiration handpieces is recommended to avoid stretch-
ing and stressing the capsulotomy, as well as by using
lower, safer, and slower phacoemulsification settings.41
Day et al.39 found a low rate (0.1%; 1 in 1000 cases) of
anterior capsule tear in FLC; the authors believe that such
low rate was due to upgraded software version of the
Catalys platform and differences in laser delivery
between platforms.
Staining of the anterior capsule is not routinely per-
formed in FLACS.6,34,42 Some authors recommend to stain
the anterior capsule in the initial few FLACS cases, as the
procedure has a learning curve even in experienced PCS
surgeons.43 On the other hand, routine staining of the ante-
rior capsule could be beneficial for identifying incomplete
capsulotomies or anterior capsule tags and radial tears.
Utility of FLACS in advanced cataracts
A significant difficulty of surgery in white cataracts is to
perform a perfect CCC; problems encountered during
this step of surgery include the lack of the red reflex,
elevated intralenticular pressure and the fragility of the
anterior capsule. Thus, up to 28.3% of manual PCS white
cataract cases might have an incomplete capsulorhexis.44
A pilot study reported potential advantages of FLACS in
25 eyes with white cataracts, as the laser created a per-
fectly rounded and adequately sized capsulotomy, and
allowed to avoid intraoperative capsule complications
associated with increased intracapsular pressure.45
However, a significant problem in these cases might be
the outflow of milky white into the anterior chamber dur-
ing FLC which can block the laser shots targeted on the
capsule.46 In a single investigation, up to 47.5% of eyes
with white cataract demonstrated microadhesions and
incomplete FLCs.47 In another study, 17.2% of FLACS
cases had an incomplete capsulotomy, and in multiple
logistic regression greater lens thickness was found to be
a risk factor for an incomplete capsulotomy.48 Thus,
Schultz and Dick49 recommended creating a femtosecond
laser mini-capsulotomy which decreases the intralenticu-
lar pressure, subsequent manual rinsing of the milky fluid
released into anterior chamber, and then re-docking the
laser to create the final larger capsulotomy. Unfortunately,
this technique may not be feasible in settings where the
laser is situated in a separate operating room, or on some
commercially available laser platforms.46
Studies analyzing the risks of intraoperative complica-
tions in individuals with white cataracts did not provide
indisputable evidence on the clinical benefits of FLACS
compared with conventional PCS. In a large investigation
on 132 eyes with white cataracts, Zhu et al.50 reported a
lower risk of anterior capsule tears in FLACS than in man-
ual PCS (0% vs 12.1%; p = 0.007). However, the risk of
posterior capsule rupture (PCR) which is elevated in white
cataracts51 did not differ between the FLACS and PCS
group (1.5% vs 6.1%; p = 0.362).50 In a study by Taravella
et al.,52 11.7% of white cataract cases undergoing FLACS
developed PCR, which is in agreement with the PCR rate
of previous studies in manual PCS.53 Another issue is the
problem with performing FLACS lens fragmentation in
white cataracts; the laser might be unable to penetrate
through the opaque lens material and perform nucleus sof-
tening or segmentation.54 Chee et al.48 reported that only in
81.6% of white cataract cases the laser lens fragmentation
was effective or partially effective. Moreover, in
Morgagnian cataracts the laser lens fragmentation is disad-
vised due to the chance of overlapping of the lens frag-
mentation plan and the anterior capsule.48 The utility of
FLACS was also demonstrated in traumatic,55 sublux-
ated,56 and polar cataracts.57,58 We have not found evidence
to support the use of staining in white cataracts while using
the femtosecond laser. We might conclude there is lack of
unequivocal evidence to recommend FLACS in advanced
cataract cases; additional studies are required to establish a
definitive intraoperative advantage of FLACS compared
with manual PCS in such eyes.54
Phacoemulsification energy during lens removal
and influence on the endothelium
Preliminary studies have shown that femtosecond pretreat-
ment allows to reduce the effective phacoemulsification
time (EPT) by 83.6% comparing with conventional PCS,
with 30% of cases having a zero-second EPT.59 The reduc-
tion of EPT in FLACS was confirmed in several subsequent
studies.60–63 Moreover, it was suggested that a further reduc-
tion might be achieved with improved laser pretreatment
algorithms and by using a 20-gauge phacoemulsification
tip.60 Importantly, the reduction in EPT might translate into
lower endothelial cell loss: in a study by Conrad-Hengerer
et al.,60 patients having undergone FLACS manifested lower
endothelial cell loss (8.1% ± 8.1%) than those after manual
PCS (13.7% ± 8.4%) 3 months postoperatively (p < 0.001).
Another investigation reported a slightly lower endothelial
cell loss in FLACS than in PCS at 180 days after surgery
(21.0% in FLACS vs 30% in PCS; p = 0.073).61 On the other
hand, Yesilirmak et al.64 presented that EPT was lower for
FLACS than for PCS only in inexperienced surgeons; how-
ever, FLACS pretreatment decreased the total nucleus
removal time regardless of the surgeons’ experience. In
another study, which analyzed the cases based on the grade
of cataract, a reduction of endothelial cell density in FLACS
compared with manual PCS was noted both in mild and
advanced cataracts.65 In hard nuclear cataracts, the endothe-
lial cell damage is greater than in soft cataracts due to high
Kanclerz and Alio 5
EPT. Thus, it was also shown that particularly in hard cata-
ract cases FLACS might provide a significant reduction in
endothelial cell damage and provide faster visual rehabilita-
tion than PCS.66 The reduction in endothelial cell loss might
translate into lower risk of corneal decompensation, and this
benefit is critical in individuals with Fuchs endothelial dys-
trophy.65 In a study by Yong et al.,65 individuals with Fuchs
endothelial dystrophy and a mild cataract having undergone
FLACS experienced a decrease of endothelial cell density
by 0.9% ± 22.5%, while those with moderate or severe cata-
racts had a reduction by 8.2% ± 26.3%. It might be con-
cluded that due to a shorter EPT, FLACS is beneficial in
patients with lower baseline endothelial cell count.
Pupil size during surgery
A significant problem and drawback of FLACS is intraop-
erative miosis. In an investigation by Nagy et al.,40 the rate
of intraoperative miosis reached 32% of cases. Intraoperative
miosis in FLACS is associated with prostaglandin release
into the anterior chamber even before the first surgical
instrument is introduced into the eye.67–69 Moreover, the
magnitude of miosis is correlated with the concentration of
intracameral interleukin-6.70 Risk factors for intraoperative
miosis during FLACS include longer laser pretreatment
duration and older patient age.71 Also other factors such as
short pupil-capsulotomy distance, shallow anterior cham-
ber, smaller pre-operative pupil size, and longer suction
time are associated with intraoperative miosis.72
In order to prevent intraoperative difficulties associated
with a small pupil, non-steroidal anti-inflammatory drugs
should be applied three to four times on the day prior to
surgery, and in the morning before surgery.70,73,74 In a study
by Anisimova et al.,70 bromfenac 0.9% prevented the inci-
dence of miosis better than indomethacin 0.1%. Walter
et al.67 suggested adding 4 mL of a phenylephrine
0.1%–ketorolac 0.3% (Omidria; Omeros Corporation,
Seattle, WA) solution to 500 mL of eye-irrigation fluid. In
their study, such an application resulted in reducing the
duration of surgery and the need for pupil expansion
devices in FLACS surgery.67
An overview of postoperative benefits
and drawbacks of FLACS
The prevalence of postoperative complications of FLACS
is presented in Table 2.
Pseudophakic cystoid macular edema
Pseudophakic cystoid macular edema (PCME) is one of
the most frequent causes of poor visual outcome after
PCS.76 Surgical manipulations performed in the anterior
chamber result in the release of arachidonic acid from the
uveal tissue with the production of leukotrienes (catalyzed
by the lipoxygenase) and prostaglandins (catalyzed by the
cyclooxygenase enzymes). Consequently, posterior diffu-
sion of the inflammation indicators to the vitreous might
cause disruption of the blood–retinal barrier; such break-
down results in an increase of the perifoveal capillary per-
meability and subsequent macular edema.77,78 As the
FLACS operation employs supplementary maneuvers (i.e.
docking or applanation) and the eye is subjected to an
energy other than ultrasound, concerns related to the risks
of PCME in FLACS arose.
In a study by Ewe et al.,79 published in 2015 the inci-
dence of PCME was non-significantly higher in FLACS
(0.8%) than in conventional PCS (0.2%; p = 0.07). In their
subsequent study, PCME was reported in 8 of 988 eyes fol-
lowing FLACS (0.81%), but only in 1 of 888 eyes following
PCS (0.1%; p = 0.041).80 On the other hand, Conrad-
Hengerer et al.81 found no difference in postoperative macu-
lar thickness in FLACS and PCS. Another investigation
analyzed the postoperative PCME rates in optical coherence
tomography (OCT) examinations; PCME occurred in
0.98% cases in the PCS group (7/713), and in 1.18% of eyes
(8/677) in the FLACS group, not significantly different.82
According to the Cochrane review, it was not possible
to determine the equivalence or superiority of FLACS
compared with PCS in terms of PCME risk, based on ran-
domized controlled trials.83 The risk of developing PCME
based solely on randomized controlled trials was lower in
FLACS than in conventional PCS with the odds ratio 0.58
(95% CI: 0.20%–1.68%). However, the quality of evi-
dence was assessed as low; large, adequately powered
studies would still be required.
Posterior capsule opacification
FLC induces greater apoptosis of the lens epithelial cells
situated along the capsulotomy cutting edge compared
with manual CCC.84 The level of lens epithelial cell apop-
tosis in FLC is linearly correlated with the femtosecond
laser duration, and the process is associated with laser
energy absorption, photodisruption-dependent plasma for-
mation, and subsequent creation of cavitation bubbles.85,86
It was shown that the detrimental apoptotic and inflamma-
tory effect can be minimized by reducing the laser energy
levels.87 As the lens epithelial cells proliferation after PCS
is partially responsible for posterior capsule opacification
(PCO),88,89 theoretically the apoptotic effect of FLACS
could negatively influence PCO formation.85 Nevertheless,
in clinical investigations, the PCO rates in FLACS were
not lower than in conventional PCS. Moreover, a study by
Rostami et al.90 reported a relatively high rate of fibrotic
PCO formation within 3 months following FLACS (in 7
out of 29 cases). The rate of PCO in the aforementioned
study was presumably associated with the FLACS learn-
ing curve and not employing anterior capsule polishing
within the study. Another plausible explanation is that the
6 European Journal of Ophthalmology 00(0)
energy employed in FLACS induces epithelial-to-mesen-
chymal cell transition which is partially responsible for
PCO development.86 A larger study by Manning et al.9 did
not confirm such high rates of PCO in FLACS; however,
the rate of early PCO was still higher in FLACS (0.9%)
than in conventional PCS (0.0%; p < 0.001).
Visual outcome
Vasavada et al.91 reported that in eyes with a shallow ante-
rior chamber, FLACS generated less corneal edema and
inflammation on POD1 and POD7 compared with conven-
tional PCS. Patients after FLACS had a smaller postopera-
tive refractive error compared with PCS.92 Nevertheless,
the final corrected visual acuity and surgical astigmatism
do not differ between PCS and FLACS.92
In the European Registry of Quality Outcomes for
Cataract and Refractive Surgery database, FLACS did not
improve the visual or refractive outcomes when compared
with routine PCS.9 Similarly, in the study by Berk42
(which compared results of 1089 eyes having undergone
FLACS and 883 eyes having undergone PCS), there was
no difference in refractive and visual outcomes. Finally,
the results of the FEMCAT study performed in France,
which involved 16 clinical centers and 1400 eyes of 870
patients, reported no difference in overall clinical out-
comes (including complication rates, postoperative visual
acuity, refractive error, and change in corneal astigma-
tism) between FLACS and PCS.93 A trend toward better
outcomes for lower grade cataracts was observed in the
FLACS group, while a trend toward better outcomes for
the highest grade cataracts in the PCS group (not signifi-
cantly different).
Cost-effectiveness
Several expenditures should be considered when analyz-
ing the total cost of a single FLACS case. First, the cost of
obtaining and maintenance of the femtosecond laser. In
some cases, it is possible to utilize the same platform for
laser in situ keratomileusis (LASIK) flap creation and
FLACS (e.g. Alcon LenSx, Bausch + Lomb Victus,
Ziemer Femto LDV Z8); however, some FLACS lasers
might be unable to create LASIK flaps (Johnson & Johnson
Catalys, the LensAR system), while other lasers dedicated
for flap creation are not capable of performing FLACS
(Ziemer Femto LDV Z2/Z4/Z6). In such cases, a separate
laser platform for refractive and cataract surgery would be
required.
According to Roberts et al.,94 the main cost of a FLACS
procedure is the disposable patient interface, which is
higher than the capital cost of the laser device itself.
Employing the FLACS platform might require assistance
of a trained technician, who would usually support the
workflow with the laser platform. Another issue is that
additional steps required for FLACS take time. In a study
by Lubahn et al.,95 FLACS cases were 11.1–12.1 min
longer than PCS. Although with increased surgeon’s expe-
rience the duration of surgery decreased, it was still sig-
nificantly longer than with conventional PCS.19 Another
Table 2. Prevalence of postoperative complications in PCS and FLACS in selected cohort studies.
Method PCS FLACS
Study Jaycock et al.8
(n = 16,731)
Syed et al.7
(n = 20,070)
Greenberg et al.75
(n = 45,082)
Manning et al.9
(n = 2814)
Posterior capsule opacification (%) 1.22 0.34 4.2 0.9
Corneal edema/striae/Descemet folds (%) 5.18 0.59 N/A 0.5
Postoperative uveitis (%) 3.29 0.24 N/A 0.5
Raised IOP (>21 mmHg) (%) 2.57 0.31 N/A 0.2
IOL decentration/dislocation/exchange (%) 0.22 N/A 0.9 0.0
Cystoid macular edema (%) 1.62 0.22 3.3 N/A
Iris prolapse/iris to wound (%) 0.16 0.04 N/A N/A
Retained soft lens matter (%) 0.45 0.19 1.7 N/A
Vitreous to section (%) 0.39 0.09 N/A N/A
Wound leak (%) 0.14 0.02 N/A N/A
Choroidal effusion/hemorrhage (%) 0.13 N/A 0.1 N/A
Hyphema (%) 0.07 N/A 0.2 N/A
Hypopyon/endophthalmitis (%) N/A 0.04 0.2 N/A
Retinal tear or detachment (%) N/A 0.03 1.0 N/A
Vitreous hemorrhage (%) N/A 0.01 0.4 N/A
Hypotony (%) N/A N/A 0.1 N/A
IOL: intraocular lens; IOP: intraocular pressure; N/A: not available; PCS: phacoemulsification cataract surgery; FLACS: femtosecond laser-assisted
cataract surgery.
Kanclerz and Alio 7
study reported that only the duration of intraoperative suc-
tion, which is employed in FLACS but not in PCS, was
6.72 ± 4.57 min (range: 2–28 min).96
Taking into consideration that it is a cost for both the
clinic and for the patients, one cannot consider FLACS to
be cost-effective.97 In order to achieve cost-effectiveness,
FLACS should significantly lower the complication rate
and reduce the cost to the patients.98 In any case, a finan-
cial analysis should be performed before the purchase of a
femtosecond laser.99
Conclusion
The benefits and drawbacks of FLACS have been pre-
sented in Table 3. One might conclude that some groups of
patients, that is, with low baseline endothelial cell count,
or those planning to receive multifocal IOLs might benefit
from FLACS. Nevertheless, having considered that the
advantages of FLACS might not be clear in every routine
case, it cannot be considered as cost-effective.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of inter-
est with respect to the research, authorship, and/or publication of
this article: Dr Kanclerz reports non-financial support from
Visim and Optopol Technologies.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article:
This publication has been supported in part by the Red Temática
de Investigación Cooperativa en Salud (RETICS), reference
number RD16/0008/0012, financed by the Instituto Carlos III—
General Subdirection of Networks and Cooperative Investigation
Centers (R&D&I National Plan 2008–2011) and the European
Regional Development Fund (Fondo Europeo de Desarrollo
Regional FEDER) (Grant from Jorge L. Alio, P.I). The authors
have no proprietary or commercial interest in the medical devices
that are involved in this manuscript.
ORCID iDs
Piotr Kanclerz https://orcid.org/0000-0002-8036-7691
Jorge L Alio https://orcid.org/0000-0002-8082-1751
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