Viewpoint

Coming Around on FLACS

From The Chief Medical Editor
Larry E. Patterson, MD

After last year's AAO meeting, I had misgivings about femtosecond laser-assisted cataract surgery. (I'm disappointed to report that my acronym, FLACS, hasn't yet gone mainstream, but I'm still hopeful.) Only one system was approved, there was confusion about charging patients, and the laser added extra time to an already very efficient procedure.

How things have changed as we head into this year's meeting. There are now five FDA-approved femtosecond lasers capable of performing at least part of the surgery. A position paper from the AAO/ASCRS clarified when one can charge the patient. But the thing that remained unsolved for me was the work flow. The laser treatment seemed to me to nearly double the time it would take to perform a case.

Fortunately for me I had the chance to observe FLACS in action this summer at the Eye Center of Central Pennsylvania. My purpose for visiting was to observe a seasoned practice that had the same EHR system I recently started using and get some tips on using it efficiently. But the administrator, Bob Lamont, seemed excited about making sure I saw their recently purchased femtosecond laser for cataract surgery. I happily obliged him, and I'm really glad I did.

While observing Dr. Scott Hartzell perform impeccable surgery, I learned a process to make this work. They have two ORs, one housing the laser off to the side. Having a 20-by-20-foot space helped.

When the doctor entered the room, the patient was positioned under the laser. The doctor did the final programming checks, docked the laser, and performed the treatment. He then scrubbed and gowned while the patient was rolled a few feet over under the operating microscope and was prepped.

Here was the amazing part. Dr. Hartzell's first step in the operation was to put the phaco handpiece tip into the eye! His perfect triplanar incision was already constructed, LRI's cut, the capsulotomy was complete, and the nucleus subdivided. The phaco went very quickly, the operation was a success. Dr. Hartzell estimates that most routine cases require about 90-120 seconds to perform the laser portion. You'll save about that much time doing the cataract surgery, so overall it's a wash.

I also watched Dr. Daniel Fassero see pre-op patients in the clinic and discuss options to potential candidates. There was no hard sell, just a balanced explanation of the differences in conventional and laser surgery and the pros and cons of each. Even in this rural practice, around 25% of their cataract patients are choosing FLACS.

Again, I'm not running out and buying one just yet. I can't afford it. I'm still deep in EHR debt. But I'm seeing it as a future viable option, a dim light at the end of the tunnel. Who knows? Maybe prices will come down. Happy shopping next month.