Laser-assisted cataract surgery (FLACS) uses a femtosecond laser to automate several steps of conventional cataract surgery. It is marketed at some surgical centres as "bladeless," "computer-guided," or "more precise", and carries a significant additional fee. An honest review of the published evidence suggests that for the majority of patients undergoing routine cataract surgery, FLACS does not produce meaningfully better outcomes than conventional phacoemulsification in experienced hands.
What Conventional Phacoemulsification Involves
Conventional phacoemulsification cataract surgery involves a small self-sealing corneal incision (typically 2.2–2.4mm), a hand-made circular anterior capsulotomy (capsulorhexis), and ultrasound emulsification and aspiration of the cloudy lens, followed by IOL implantation. The procedure takes approximately 15–20 minutes in experienced hands, requires no laser, and has an excellent safety record, with serious complication rates well below 1% for routine cases in experienced hands.
In conventional cataract surgery (phacoemulsification), the surgeon makes a small self-sealing corneal incision (typically 2.2–2.4mm) with a micro-keratome blade, creates a continuous circular capsulotomy (capsulorhexis) by hand under the surgical microscope, and uses an ultrasound phacoemulsification probe to emulsify and aspirate the lens. An IOL is then folded and implanted. The procedure takes approximately 15–20 minutes in experienced hands.
What FLACS Adds
FLACS uses a femtosecond laser to perform three steps before phacoemulsification begins: the corneal incisions, the anterior capsulotomy, and pre-fragmentation of the lens nucleus. A docking device is applied to the eye under OCT imaging guidance. The surgeon then proceeds with phacoemulsification to remove the pre-fragmented lens and implant the IOL. FLACS supplements phacoemulsification; it does not replace the ultrasound step, which is still required to aspirate the lens material.
FLACS uses a femtosecond laser, the same laser platform used in LASIK surgery, to perform several pre-operative steps before phacoemulsification begins. A docking device is applied to the eye, and under OCT imaging guidance, the laser performs:
- The corneal incisions
- The capsulorhexis (circular opening in the anterior lens capsule)
- Pre-fragmentation of the lens nucleus into segments
The surgeon then proceeds with phacoemulsification to remove the pre-fragmented lens pieces and implant the IOL. FLACS does not replace the phacoemulsification step — it supplements it.
What Does the Evidence Show?
Multiple large randomised controlled trials and systematic reviews comparing FLACS with conventional phacoemulsification in routine cataract patients have consistently found no significant difference in final visual acuity and no reduction in serious complication rates. Some advantages of FLACS — marginally less phacoemulsification energy used, potentially more precise capsulotomy size — have not translated into measurable improvements in clinical outcomes in most series. Some FLACS series have reported higher anterior capsule tag or tear rates.
Multiple large randomised controlled trials and systematic reviews have compared FLACS with conventional phacoemulsification in routine cataract patients. The consistent findings are:
- No significant difference in final visual acuity in routine cases
- No reduction in serious complication rates (posterior capsule rupture, endophthalmitis) in routine cases
- Marginally less phacoemulsification ultrasound energy used (due to pre-fragmentation) — but this has not translated into better clinical outcomes in routine surgery
- Possibly marginally more precise capsulorhexis size and centration — but this has not produced a measurable improvement in IOL centration or refractive outcomes in most series
- Higher rates of anterior capsule tags or tears in some FLACS series (the softened capsule after laser treatment is more prone to tearing)
Is FLACS Safer?
For routine cataract surgery, the current evidence does not support FLACS as safer than conventional phacoemulsification by an experienced surgeon. The docking step introduces its own potential complications, including corneal abrasion, subconjunctival haemorrhage, and incomplete docking, and the most feared serious complication of cataract surgery (posterior capsule rupture) has not been shown to be reduced by FLACS in routine cases. Some series have reported higher anterior capsule tear rates with FLACS compared with manual capsulorhexis in experienced hands.
For routine cataract surgery, the current evidence does not support FLACS as safer than conventional phacoemulsification. The docking step adds its own potential complications: corneal abrasion or oedema from suction, subconjunctival haemorrhage, incomplete docking, and patient discomfort during the suction phase. These are generally minor, but they are additional steps in a procedure that, without FLACS, requires no pre-operative docking. The most feared serious complication of cataract surgery, posterior capsule rupture, has not been shown to be reduced by FLACS in routine cases.
Does FLACS Cost More?
Yes, substantially. A femtosecond laser machine costs $500,000 or more, with significant ongoing maintenance, software licence, and per-procedure consumable costs. In Melbourne, these are typically passed to patients as an additional facility fee of $500–$1,000 or more per eye, above the standard cataract surgery cost. This additional fee is generally not covered by Medicare or private health insurance beyond the standard cataract surgery rebate.
Yes, substantially. A femtosecond laser machine costs $500,000 or more and requires significant ongoing maintenance, software licences, and per-procedure consumable costs. These are passed to patients as an additional facility fee, typically $500–$1,000+ per eye in Melbourne, above the standard cataract surgery cost. This additional fee is generally not covered by Medicare or private health insurance beyond the standard cataract surgery rebate.
My View
I perform conventional phacoemulsification and do not routinely offer FLACS, based on the current evidence. The published evidence does not support routine FLACS over conventional phacoemulsification for most patients, and I am not in a position to recommend a more expensive procedure when it does not demonstrate a clinical benefit for the cases I treat. The outcomes achievable with modern phacoemulsification equipment in experienced hands are excellent; what matters most is accurate biometry, appropriate lens selection, and precise surgical technique, not the addition of a laser at the incision step.
I perform conventional phacoemulsification. The published evidence does not support routine FLACS over conventional phacoemulsification for most patients, and I am not in a position to recommend a more expensive procedure when it does not demonstrate a clinical benefit for the majority of cases I treat. The outcomes achievable with modern phacoemulsification equipment in experienced hands are excellent. What matters most for your cataract surgery outcome is accurate biometry, appropriate lens selection, precise surgical technique, and thorough patient counselling, not the addition of a laser at the incision step.
If you are considering cataract surgery and have been offered FLACS, I would encourage you to ask your surgeon to explain specifically what benefit the laser provides for your individual case, and why that benefit justifies the additional cost.