I REFER to the letter “Laser procedure involves extra cost and time” (The Star, March 6), expressing concerns over the report “Cataract surgery safer with laser” (The Star, March 4). The concerns focused mainly on the writer’s disbelief that Femtosecond Laser Assisted Cataract Surgery (FLACS) is safer or faster than the conventional Phacoemulsification Cataract Surgery (Phaco).
I have been an eye surgeon since the early 1990s. Over the years, I’ve witnessed the emergence of many surgical technologies in Asia including FemtoLASIK, Implantable Contact Lenses (ICL) and various cataract surgery technologies.
Though Phaco would become the standard of cataract practice worldwide after its introduction in 1967, much has changed since then. Phaco involves the surgeon manually creating cuts, openings and breaking the cataract with metal blades and instruments, which was ironically explained to patients as “laser” eye surgery.
FLACS resulted from the success of femtosecond laser technology used in laser eye surgery (Lasik) to create Lasik flaps in 2001. Similarly, when first introduced for Lasik, disbelieving surgeons continued to use blades to make Lasik flaps. Now, however, most Lasik centres use femtosecond laser technology for Lasik procedures, becoming the gold standard for it worldwide.
Approved for use in cataract surgery in 2009, FLACS effectively replaces some key steps performed manually by the surgeon during Phaco. This includes creating corneal incisions, opening the anterior lens capsule (capsulotomy) and dividing the cataract into smaller portions (lens fragmentation). FLACS is also able to correct astigmatism, the major cause of blurred vision.
Emergence of FLACS has changed cataract practice worldwide, allowing the surgeon to perform cataract surgery in a more predictable and precise manner. This increases the likelihood of getting the best outcome and safety, especially with complex cases.
More importantly, most of the procedure is completed before the surgeon even attempts to go into the eye – which is only possible with a laser.
In over 4,000 cases performed in my practice alone, FLACS proved to be highly beneficial for both surgeons and patients and without any significant complications or side effects. FLACS continues to improve alongside technological advancements, shortening the learning curve for surgeons and improving its outcomes.
Many of the reported risks stated in the aforementioned letter were transient (temporary) and mostly resolved now. FLACS incisions are rendered more accurate, predictable and reproducible. Moreover, the new-generation low pulse energy femtosecond laser enables the surgeon to easily open the corneal incision without a surgical blade (hence the term “no-blade cataract surgery”).
Though Phaco may take 15 minutes for experienced surgeons, the majority of cases may be longer, depending on the type of cataract and other factors. A surgeon may require minutes to break a mature cataract into pieces before its removal, but the laser is able to do it within seconds. In our practice, experienced surgeons have averaged around 15 minutes per surgery with FLACS.
In terms of complications and side effects, both FLACS and Phaco share similar incidences. However, FLACS remains a safe procedure for cataract treatment even for glaucoma patients. Prospective and randomised studies show that although there is a rise in intraocular pressure (IOP) when using a vacuum suction cup during FLACS, the effect was transient and well tolerated (not dangerous).
Furthermore, newer FLACS platforms have not only lowered IOP elevation rates but also reduced incidence of eye inflammation after surgery.
Advancement in FLACS technology has also enabled surgeons to create smooth-edged cuts, minimising the risk of radial tears. Additionally, with the liquid immersion interface, incidence of incomplete capsulotomies are eliminated, further reducing the risk of capsulotomy breakages.
With the OCT, capsulotomy has been rendered more precise and centred, resulting in better visual results especially for premium lenses such as multifocals and, more recently, trifocals.
Many clinical studies incorporating advancements in technology, techniques and data in FLACS have emerged to verify the efficacy and benefits outlined above. Scientific literature on FLACS has provided over 250 peer-reviewed articles including randomised controlled trials, cohort studies, case reports and editorials by reputable experts and research bodies. This ensures balance and objectivity in the analyses of FLACS.
This is important as the use of any one study, without taking into account their design and/or sampling methods, may result in potentially misleading impressions and/or conclusions.
For example, the letter quoted the 2016 European Registry of Quality Outcome for Cataract and Refractive Surgery (EUREQUO) study as the largest in the world comparing FLACS and Phaco to date. In truth, this registry-based EUREQUO study compared only 2,814 FLACS eyes and 4,987 Phaco eyes (total of 7,801) and not 20,000 patients as stated.
After an even larger study (9,400 FLACS vs 8,779 Phaco cases), renowned ophthalmic surgeon Dr Thomas Kohnen reported in February 2017 to an international ophthalmology conference that FLACS does have better visual results and overall superior safety profile.
As the number of younger patients increases, expectations of their cataract surgery have also increased significantly. Mostly still working and more knowledgeable, their desire for spectacle-independence, better surgical results and faster recovery drives them to search for better technology and treatments.
While new technology comes with added cost, nonetheless we need to weigh it against the benefits it brings. Furthermore, as with any technology, there will be continuous improvements that render it even more effective and accessible to all.
Though most surgeons in Malaysia still use conventional Phaco, it does not mean they don’t agree that FLACS has its advantages. The major barrier to ultimately accepting FLACS is the high investment in time and money needed to implement it. In a time of evolving technology, it is our responsibility as medical advisers to guide patients with proper, updated and appropriate information to allow them to make informed decisions.