Study Finds Faster Recovery With FLACS In Vitrectomized Eyes

Sumit (Sam) Garg, MD


January 26, 2023

Femtosecond laser-assisted cataract surgery (FLACS) was approved in the United States in 2009. Since that time, various publications have compared conventional surgery with FLACS. Many studies have shown no significant difference between conventional surgery and FLACS with respect to best corrected vision several months after surgery.

As true with most technologies, those who have the technology find that there are benefits to it, and those who don't have the technology often find reasons why the technology is not needed for their practice. With FLACS, there is certainly a substantial capital cost to adoption, which is likely part of the reason that the technology has not become more mainstream.

Personally, I offer FLACS to appropriate patients. For example, FLACS can benefit many of my patients with refractive cataracts and those with complex eye disorders, such as Fuchs endothelial dystrophy, dense cataracts, shallow anterior chambers, pseudoexfoliation, and post-vitrectomy.

But not every patient with cataracts is a candidate. In particular, patients who have poor pupillary dilation, as well as those who opt for conventional monofocal implanted lenses who don't mind wearing spectacles for any or all activities, may not be ideal candidates for FLACS. For those patients who may not benefit, I review the indications, risks, and benefits and let them know why I am not recommending FLACS for them.

In this installment of Viewpoints, I present new evidence on the benefits and risks of FLACS in patients with dense cataracts with prior pars plana vitrectomy (PPV). In the December 2022 Journal of Cataract & Refractive Surgery, Cai and colleagues report results from a randomized prospective study of FLACS compared with conventional phacoemulsification for complex cataracts in vitrectomized eyes of 100 patients.

The researchers report less use of ultrasound energy in the FLACS group, which led to faster visual recovery, less loss of endothelial cells, and faster recovery of central corneal thickness in this cohort of dense cataracts post-PPV. But they found some of the FLACS cases had incomplete capsulotomies due to residual silicone oil bubbles. In the conventional group, on the other hand, they noted a higher incidence of zonule dialysis compared with the FLACS group.

It is not uncommon for patients to have significantly dense cataracts after PPV. These patients also have a higher tendency for zonular instability because of their prior PPV. This prospective study supports use of FLACS in these difficult eyes.

In my own practice, I have found that FLACS can be of benefit in these challenging cases. For example, the ability to have a perfectly centered capsulotomy allows for optic capture in the case of a posterior capsular tear that requires sulcus placement of the intraocular lens. Fragmentation of the nucleus is helpful in these patients because they often have dense nuclei with leathery posterior fibers. Although not all post-PPV eyes will be suitable candidates for FLACS, surgeons should carefully weigh the potential candidacy of their patients with post-PPV cataracts for FLACS.  

Sumit (Sam) Garg, MD, is the vice chair of clinical ophthalmology and an associate professor in the Department of Ophthalmology at the Gavin Herbert Eye Institute, University of California, in Irvine. He specializes in corneal and cataract surgery as well as laser refractive surgery.

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