Eyeworld

EW CATARACT 32 December 2016 by Vanessa Caceres EyeWorld Contributing Writer FLACS takes some flak Dr. Braga-Mele said she performs FLACS procedures, but she cites fi- nancial and clinical challenges with its use that make it less favorable for the time being. First, there is the cost of the laser itself, and she urged practices to perform a financial analysis before investing in the laser. There are also time considerations, such as the time involved in surgeons learning to use the technology, the addition- al few minutes it takes each FLACS patient (this time may be longer initially during a surgeon's learning curve, she added), and the logistics of incorporating laser use. There also may be time involved in dilating a patient's eye a second time after laser application if that becomes neces- sary, Dr. Braga-Mele added, due to the release of inflammatory agents within the eye with FLACS. There are possible clinical com- plications with FLACS, including an increased risk for cystoid macular edema. Dr. Braga-Mele shared data from the 2016 ASCRS Clinical Survey that found only 8% of patients have FLACS done now, of his cataract patients have had FLACS. Use of the laser offers a more centered capsulotomy, less energy is used in the eye, and physicians not traditionally comfortable with limbal relaxing incisions can perform them with FLACS. "Most doctors who wouldn't con- sider refractive cataract surgery now have the chance to perform it," Dr. Donnenfeld said. Although the evidence is not clear as to whether FLACS leads to better vision, Dr. Donnenfeld thinks it boosts the skill level of average surgeons. "The challenge of demon- strating the advantages is when you take top surgeons and look at the results, you don't see a huge delta. For surgeons who aren't as skilled, there's a definite advantage," he said. Economically speaking, sur- geons must be willing to charge a certain dollar amount for FLACS use and perform a minimum number of cases. If ownership of the laser is not possible, there are roll-on/roll-off options available, Dr. Donnenfeld added. then, he has performed more than 2,600 cases in routine and premium patients. "That represents 35% of all [my] cases, but it does not include any complex cataract procedures that this technology is helping with immensely," Dr. Cionni said. Industry data show a continu- ing rise in use of FLACS technology in the U.S. and a growing number of surgeons who are trained in it, he added. Although most published stud- ies have not demonstrated refrac- tive superiority for FLACS, there is research that shows it can offer quicker recovery and stability, fewer higher-order aberrations, and a greater ability to reach the refractive target, Dr. Cionni said. One factor that has affected study results so far has been effective lens position (ELP). "The noise that is introduced into the IOL calcu- lation by ELP is simply too great to demonstrate superiority in one technique over the other," said Dr. Cionni, referring to FLACS versus manual phacoemulsification. Studies also need to use contralateral eyes to truly show head-to-head results, he added. One strong advantage with FLACS is within astigmatism. "The laser's ability to give us a very pre- cise depth, meridional alignment, and optical zone placement of the arcuate incisions is more precise than what anyone can do by hand," he said. Dr. Cionni has found FLACS use easier in managing difficult cases, such as in brunescent cataracts and zonular compromised patients. "There's no evidence that the refrac- tive result with FLACS is worse, and we do have some evidence that it's better. It certainly is very helpful in these challenging cases," he said. Although femtosecond lasers can be expensive, the use of FLACS is not adding costs to Medicare or private insurance, as patients pay for the technology, Dr. Cionni said. "Not every patient can afford or will want to pay for this. However, many do, and those that do more than support the cost of our surgery center," he said. To add to the arguments in favor of FLACS, Eric Donnenfeld, MD, clinical professor of ophthal- mology, New York University Medi- cal Center, New York, said that 50% FLACS: Friend or foe to refractive cataract surgeons? F emtosecond laser-assisted cataract surgery (FLACS) has been at the forefront of most cataract surgery discussions over the last few years. There have been many recent papers that show there are some potential advantages and some disadvantages in implementing FLACS. There are always two sides to a story, and in this article, Robert Cionni, MD, and myself debate the pros and cons of FLACS. We also have opinions from two heavy hitters in the cataract field, Eric Donnenfeld, MD, and Richard Lindstrom, MD, on the current state of FLACS. FLACS is definitely here to stay in some form or another. Improvements will be made, and we will likely see significant movement toward integrating this proce- dure into our practices. For now, the debate continues. Rosa Braga-Mele, MD, MEd, FRCSC, Cataract editor Clinicians weigh in on personal experience and outcomes F emtosecond laser-assisted cataract surgery (FLACS) generates a lot of buzz with- in ophthalmology, but is there a true winner in a pro and con debate on the technology? During a session at the 2016 American Academy of Ophthalmol- ogy (AAO) annual meeting, Robert Cionni, MD, medical director, The Eye Institute of Utah, and adjunct clinical professor, John A. Moran Eye Center, University of Utah, Salt Lake City, spoke in favor of FLACS, while Rosa Braga-Mele, MD, FRCSC, pro- fessor of ophthalmology, University of Toronto, and director of cataract surgery, Kensington Eye Institute, Toronto, weighed in against it. Here are highlights from their arguments —and additional thoughts from two leaders within anterior segment surgery. In favor of FLACS Dr. Cionni adopted FLACS tech- nology early on, in 2011. Since Dr. Cionni performs a variety of complex cataract and refractive procedures at his practice in Salt Lake City. Source: Robert Cionni, MD Cataract editor's corner of the world

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