12 EyeWorld Asia-Pacific | December 2024 by Ke Yao, MD, Xinyi Chen, MD FLACS is making steady progress in China Cataract surgery is one of the most frequently-performed ophthalmic surgeries worldwide, with conventional phacoemulsification surgery (CPS) becoming mainstream for decades. However, with advancements in technology, Femtosecond laser-assisted cataract surgery (FLACS), approved by the FDA in 2010, has rapidly gained traction, especially in China. FLACS was approved by the CFDA for clinical using in China in 2013, and there are more than 350 clinics to practice this new procedure and more than 400,000 cases of FLACS in China. In our eye hospital, 6500 FLACS cases were performed in 2023, accounting for 25% of the whole 26,000 cataract surgeries. FLACS uses femtosecond lasers to perform corneal incisions, anterior capsulotomy, and lens fragmentation, astigmatism correction, offering several advantages over traditional techniques. There is currently a large amount of literature discussing the clinical progress of FLACS, its benefits compared to CPS, and potential future directions. A study that our team conducted in 2016, with a followup period of 6 months found that there was not much difference between the two in terms of macular, corneal, and intraocular inflammation, indicating both FLACS and CPS achieved similar safety and efficacy outcomes.1 1542 eyes which underwent FLACS were involved in this prospective, multicenter registry study in 19 cataract surgery clinics in China to evaluate the efficacy and safety of FLACS. The completion rate of a circular anterior capsulotomy, lens fragmentation and corneal incision were 98.6%, 99.5% and 97.6%, respectively.2 Compared to conventional CPS, FLACS demonstrates multiple clinical advantages, including faster postoperative visual recovery, reduced corneal endothelial cell loss (ECL), lower surgical energy dissipation, less intraoperative complications and so on. 1. Faster Visual Recovery: Numerous clinical studies have shown that patients undergoing FLACS experience quicker visual recovery.3 Patients with hard nuclear cataracts in the FLACS group especially achieved a stable CDVA at 1 month postoperatively, while patients in the CPS group achieved this in 3 months.4 This rapid recovery is attributed to the precision and reduced tissue trauma of FLACS.2 2. Reduced Corneal Endothelial Cell Loss: One of the significant benefits of FLACS is its ability to minimize corneal endothelial cell loss, especially in cases of hard nuclear cataracts. Studies have reported that ECL in the FLACS group was approximately 7.85% three month postoperatively, while the CPS group showed a much higher rate of 19.96% after a similar postoperative period. This underscores the protective effect of femtosecond laser pre-fragmentation on the corneal endothelium.4 At the same time, individualized FLACS settings can also maximize the protective effect. Studies have shown that Grade 3 nucleus cataracts are suitable for the sextant pattern pre-fragmentation, while Grade 4 or 5 are suitable for quadrant.5 3. Lower Surgical Energy Consumption: FLACS reduces the amount of energy required during surgery because the laser pre-fragments the lens. Consequently, less ultrasound energy is needed during phacoemulsification, resulting in less intraoperative trauma to ocular tissues and shorter operative times. 4. Less intraoperative Complications: FLACS is associated with a lower rate of intraoperative complications compared to CPS. This advantage is more pronounced in complex cataracts, especially white cataracts6,7. FLACS decreased the incidence of anterior capsular tears and irregularity and decentration of capsulorhexis in white cataract from 12.1%(8/66) to 0%(0/66).7 Despite its advantages, FLACS is not without challenges. The high cost of femtosecond laser equipment is a significant barrier to its widespread adoption. But with the improvement of living standards, the impact of this issue Source: Ke Yao, MD FEATURE Pathways to Precision and Perfection – Phaco vs. Femto
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