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3 3 Supported by Abbott Medical Optics and Bausch + Lomb LACS is not appropriate for eyes with very small pupils or patients with tremors or other conditions who cannot be placed under the laser. It also may not be suited for eyes with a very fibrotic capsule or nystagmus. Conclusion The femtosecond laser provides numerous benefits in creating a capsulorhexis and performing fragmentation in cataract surgery. However, surgeons who are starting out should be well versed in phacoemulsification and each step involved before jumping into LACS. They need to be able to fall back on the basics if problems arise. References 1. Hatch KM, et al. Femtosecond laser-as- sisted compared with standard cataract surgery for removal of advanced cataracts. J Cataract Refract Surg. 2015;41:1833– 1838. 2. Chen X, et al. Comparing the curative effects between femtosecond laser-as- sisted cataract surgery and conventional phacoemulsification surgery: a meta-analy- sis. PLoS One. 2016;11:e0152088. Dr. Garg is vice chair and medical director, Department of Ophthalmol- ogy, Gavin Herbert Eye Institute, Uni- versity of California, Irvine. He can be contacted at gargs@uci.edu. LACS until they are comfortable with manual surgery. We expose residents to LACS, but their comfort zone needs to be manual cataract surgery. LACS is particularly helpful when creating a capsulorhexis in difficult cases. If the lens is decen- tered because of zonulopathy, we can center the capsulorhexis on the bag and ensure the capsulor- hexis is centered. Additionally, there is less stress on the zonules, lowering the chance of dehis- cence. In eyes with a shallow anterior chamber, it is helpful to perform the capsulorhexis with the femtosecond laser because of space considerations. With white cataracts, we do not need a red reflex to create the capsulorhexis with the femtosecond laser. How- ever, I recommend using trypan blue to be sure the capsulorhexis is complete (no residual tags) before removing it. LACS also provides frag- mentation benefits (Figure 2). When splitting moderate to dense nuclei, I think fragmentation with LACS improves EPT and results in less edema on postoperative day 1, for a faster visual recovery. It is also useful in eyes with Fuchs' dystrophy, where we need to minimize phacoemulsification energy to minimize endothelial cell trauma. LACS group. LACS cases showed significantly less EPT, mean absolute error, and phacoemulsifi- cation power and better capsulor- hexis circularity. The meta-analysis reported data from a variety of publica- tions, finding a statistical benefit to LACS in several endpoints. However, there was no benefit in CDVA (after the first week) and no significant difference in surgical- ly induced astigmatism. Some surgeons prefer conventional phacoemulsification surgery (CPS) over LACS and think they can provide good patient outcomes without laser assistance. Financial concerns should be considered when contemplating the adoption of LACS. LACS surgical benefits LACS creates a capsulorhexis that is completely repeatable in easy and difficult cases, and it is 100% circular (Figure 1). Also, we can place it exactly where we would like it (centered on the limbus, lens equator, visual axis, or other), and that is generally free-floating, unless the capsule is fibrotic. As a result, LACS reduces concerns of new surgeons. How- ever, LACS is not a substitute for traditional phacoemulsification. In our teaching institution, I dis- courage residents from performing LACS group compared with the standard phacoemulsification group. Additionally, the authors showed that brunescent (NO5) cataracts treated with LACS had similar amounts of EPT as NO3 cataracts treated with standard cataract surgery. These findings are favorable because when we treat dense cataracts with a femtosecond la- ser, reduced phacoemulsification energy and EPT generally result in less corneal edema, so we expect less endothelial cell damage and a faster visual recovery, essentially "leveling the playing field." A meta-analysis by Chen et al. compared LACS and standard phaco surgery outcomes in 9 randomized controlled trials and 15 cohort studies (total of 4,903 eyes). 2 The analysis revealed endo- thelial cell loss was significantly less in the LACS group 1 week, approximately 1 month, and 3 months after surgery versus the standard group. Central corne- al thickness was significantly lower in the LACS group 1 day, approximately 1 month, and 3 to 6 months after surgery. Correct- ed distance visual acuity 1 week after surgery was significantly better in the LACS group, and the uncorrected distance visual acuity during the final examination ap- peared significantly better in the Figure 1. Intraoperative photo demonstrating a laser capsulorhexis and pre-softened dense nucleus Figure 2. Catalys Laser System lens fragmentation

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