13 EyeWorld Asia-Pacific | December 2024 The top section illustrates the steps involved in conventional cataract surgery (CCS). The bottom section shows the steps in femtosecond laserassisted cataract surgery (FLACS), where incisions, capsulotomy, and lens fragmentation are performed using a laser. All remaining steps in FLACS are identical to those in CCS. Source: Nic Reus, MD The Cost Debate: Is FLACS Worth the Investment? A substantial difference between CCS and FLACS is the associated cost. FLACS is significantly more expensive, both in terms of equipment and the time required to perform the surgery. According to a study by Day et al. (2020), the cost of FLACS is nearly double that of conventional phaco. Additionally, the operating time for FLACS is slightly longer because the laser procedure must be performed separately from the manual steps involved in the actual cataract removal. References 1. Day AC, Burr JM, Bennett K, et al. (2020): Femtosecond laser–assisted cataract surgery compared with phacoemulsification cataract surgery: randomized noninferiority trial with 1-year outcomes. J Cataract Refract Surg 46: 1360–1367. 2. Findl O, Hirnschall N, Draschl P & Wiesinger J (2017): Effect of manual capsulorhexis size and position on intraocular lens tilt, centration, and axial position. J Cataract Refract Surg 43: 902–908. 3. Kolb CM, Shajari M, Mathys L, Herrmann E, Petermann K, Mayer WJ, Priglinger S & Kohnen T (2020): Comparison of femtosecond laser–assisted cataract surgery and conventional cataract surgery: a meta-analysis and systematic review. J Cataract Refract Surg 46: 1075–1085. 4. Wang H, Chen X, Xu J & Yao K (2023): Comparison of femtosecond laser-assisted cataract surgery and conventional phacoemulsification on corneal impact: A metaanalysis and systematic review. PLOS ONE 18: e0284181. However, FLACS may be a worthwhile investment for practices that charge patients an additional fee for the laser component, or those that perform a high volume of premium IOL surgeries. Economically speaking, CCS remains more cost-effective, especially in settings where resources are limited or where patients cannot afford the additional fees. Conclusion: Which is Better? The decision between CCS and FLACS ultimately hinges on a balance of precision, cost, and clinical outcomes. FLACS offers enhanced precision with laser-created capsulotomies and reduced phaco energy, which may benefit certain patient groups. However, these advantages do not translate into significant clinical improvements for most cases. Conventional phacoemulsification remains the gold standard for cataract surgery due to its lower cost, shorter operating time, and comparable visual outcomes. For both surgeons and patients, the choice between these two methods should be guided by individual circumstances. FLACS might be preferable for very complex cases, for surgeons with a high complication rate, or for patients seeking the latest in technological advancements. However, for most patients, CCS will deliver excellent results at a lower cost. In conclusion, while FLACS is an impressive technological advancement, conventional phaco remains a reliable, efficient, and cost-effective choice for the majority of cataract surgeries. FEATURE Pathways to Precision and Perfection – Phaco vs. Femto
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