Do you feel there are medical advantages to FLACS and if so, what are they and how often are you offering FLACS to patients?

That's a question that's sure to trigger contentious responses!

Personally, I think the capability of making toric marks on the cornea or lens capsule to line up toric lenses (and using iris registration to do so), as well as the ability to do LRIs, does offer some advantage for accuracy in astigmatism correction, especially for someone without a microscope iris registration overlay of toric axis on my actual surgical scope.

I don't think the benefit of circular, well- centered rhexes via FLACS is all that advantageous, I suppose, unless the surgeon is one who struggles with good rhexes. I also don't think the ability to do laser-assisted nuclear fragmentation is all that useful, especially in the setting of improving phaco technology. I have...

Although randomized trials have not demonstrated that femtosecond laser–assisted cataract surgery (FLACS) is superior to conventional phacoemulsification in terms of visual outcomes or complication rates, FLACS may be beneficial in cases of dense nuclei by reducing total ultrasound energy and providing a more precise, circular capsulorrhexis. These advantages can be discussed with patients when considering treatment options; however, they are often insufficient to justify out-of-pocket costs for the technology. Consequently, many physicians utilize the limbal relaxing incision (LRI) capability within FLACS platforms as a premium feature to increase patient uptake.

I have no dog in this fight, since I do not offer femto-assisted surgery. Nonetheless, I will say treating low-order astigmatism in the 1.0-1.3 range is becoming more popular. I am envious of a relatively safe method to effortlessly get rid of low-order astigmatism, like femto LRIs. There are definitely some cases where positioning a toric IOL carries some degree of unforeseen risk, in terms of the ability to adequately rotate and center the IOL (i.e., unknown zonulopathy). I do think that with astigmatism correction becoming more prevalent, the potential for complications could be lower with femto LRIs than toric IOLs, although this aspect has not been well studied. Obviously, for any sizeable amount of astigmatism, toric IOLs would become...

I personally find it helpful for Fuch's patients. I find the reduction in energy and time in the eye leads to less post-op swelling.

There have been a few studies on that topic, which say standard and femto are more or less equivalent in Fuch's patients, however. But then again, one of those studies had more time in the eye of the femto group, so your mileage may vary.

As has been mentioned, if the government came out and said you could not charge any extra for FLACS and the “business model” went away, how many of these users or super users would suddenly quit using the laser? I think the government dropped the ball on this one by allowing surgeons to charge outside the ordinary and customary for FLACS. If the technology really was game-changing, the adoption would have come despite the lack of a business model. After all, phaco machines are not free, and we can all be doing MSICS or traditional ECCE, but we find the value in a phaco machine worth the cost. The govt should have done the same with femto laser-assisted cataract surgery. I am sure someone got paid richly in that process to label it different...