Capsulorhexis Strength With FLACS Surgery

The evolution of extracapsular surgery to phacoemulsification surgery in the 1980s and 1990s was driven by patient demand and by appreciation of the dramatic benefits of the new technique. More recently, femto laser–assisted cataract surgery (FLACS) has been introduced, but the benefits of this still remain very controversial; and whether the considerable financial outlay is justifiable in terms of either a better visual outcome or a safer operation remains unproven. Indeed, the European Society of Cataract & Refractive Surgeons (ESCRS) FLACS case–control study of 2015, based on analysis of 2814 FLACS procedures from the Euroquo database, found that FLACS patients had more postoperative complications and poorer visual acuity than with standard phaco surgery. In FLACS, capsulorhexis, corneal incisions, and nuclear fragmentation are performed with unprecedented accuracy, but the ability to control size, contour, and centration of the rhexis has been cited as the major contribution of FLACS. There are, however, anecdotal reports of the rhexis having less strength and being more susceptible to tear-out. A study of over 4000 eyes in a single center showed an incidence of anterior rhexis tears of 1.84% with FLACS versus 0.22% in phaco patients¹. The paper by Reyes Lua et al.² in this issue of IOVS confirms that the rhexis is weaker in FLACS procedures and explains why this might be so—the punctate nature of the FLACS rhexis margin behaving like the perforations around a postage stamp in contrast to the smooth linear edge of a manual rhexis. It can be argued that these results are applicable to one laser manufacturer and that FLACS is a rapidly developing technology, but this paper shows that there is room for further improvement of the technology.