Author: Claude (AI), from PubMed abstracts · Reviewed by: Dr Mina Abdelmseih · Reviewed: 2026-11-15 · Review due: 2027-11-15

Educational content only. Not personalised medical advice. Clinical decisions remain the responsibility of the treating clinician.

Femtosecond laser-assisted cataract surgery

Femtosecond laser-assisted cataract surgery (FLACS) uses a laser to perform corneal incisions, capsulotomy and lens fragmentation, aiming for greater precision than manual steps, at higher cost [S6]. Large trials and meta-analyses show outcomes similar to standard phacoemulsification, and the ESCRS guideline rates the two as comparably safe and effective [S2] [S6] [S11].

Key points - A Cochrane review of 42 RCTs (7298 eyes) found probably little or no difference in complications, visual acuity or quality of life between FLACS and phacoemulsification [S6]. - The UK FACT trial (785 patients) found FLACS non-inferior for vision at 3 months but not cost-effective (ICER £167,620 per QALY) [S2]. - FLACS gives a rounder, more accurate capsulotomy and better IOL centration, and may reduce endothelial cell loss [S5] [S8] [S9]. - An earlier meta-analysis found higher risks of incomplete capsulotomy, capsulotomy tags and anterior capsule tears with FLACS [S1]; the later Cochrane review found little or no difference in anterior capsule tears [S6]. - Toric IOLs corrected astigmatism better than femtosecond laser arcuate keratotomy [S7].

Evidence last checked: 2026-10-17 (PubMed abstracts).

Red flags

• Selling FLACS as safer: pooled evidence does not show fewer overall complications [S6] [S10].
• Laser-specific capsule problems: incomplete capsulotomy (RR 22.42), anterior capsulotomy tags (RR 33.07) and anterior capsule tears (RR 4.74) were more frequent with FLACS in a 2019 meta-analysis [S1].
• Early postoperative pressure and oedema: the same meta-analysis found more macular or corneal oedema (RR 2.05) and raised IOP (RR 3.24) with FLACS [S1].

Recognise it: where FLACS may help

• Dense cataract and low endothelial counts. One meta-analysis suggests FLACS may help these patients [S8]. In a Singapore RCT of grade above 5 nuclear opacities, a 600 μm grid pattern, but not 16-segment fragmentation, reduced endothelial cell loss; acuity at 1 month did not differ [S3].
• Corneal dysfunction. Endothelial cell loss percentage was lower with FLACS up to 6 months, and corneal oedema recovered faster [S5].
• Junior surgeons. In an Indian RCT (320 eyes), FLACS used less ultrasound energy and fluid, gave clearer corneas on day 1 (72% vs 39%) and less endothelial loss at 6 months (9.3% vs 12.7%), with comparable acuity [S4].

Confirm it: what the outcomes show

• Vision. FACT: mean uncorrected acuity 0.13 vs 0.14 logMAR at 3 months; no difference in secondary outcomes at 3 months [S2]. Cochrane: a CDVA difference of about 1 letter, not clinically important [S6]. FLACS gave better CDVA at 1 week only [S10]; another meta-analysis found small UDVA and CDVA advantages at 12 months [S9].
• Posterior capsule tears. Cochrane: Peto OR 0.50 (95% CI 0.25 to 1.00), four fewer per 1000 operations, low certainty [S6]; [S8] reported OR 0.29.
• Capsulotomy and IOL position. More circular capsulorhexis, better IOL centration and lower mean absolute refractive error [S8]; fewer decentred IOLs (OR 0.06) but more subconjunctival haemorrhage [S9].
• Cost. FLACS may be the less cost-effective option [S6]; no clear cost-effectiveness advantage [S10].

Manage it

Before acting on this section, check the national and local guidelines, product information and regulatory approvals that apply where you practise. See the medical disclaimer.

Tier A (primary care / no specialist)

• Tier A / Tier B / Tier C tiers apply only partly: FLACS is a specialist-centre technology. At Tier A and Tier B, advise patients that standard surgery gives comparable results [S6] [S11].

Tier B (general eye clinic)

• Do not delay surgery to wait for FLACS: outcomes are comparable and FLACS is not cost-effective in the trials reviewed [S2] [S6].
• For astigmatism of 1.0 D or more, the ESCRS guideline recommends toric IOLs [S11]; toric IOLs outperformed laser arcuate keratotomy [S7].

Tier C (specialist centre)

• Consider FLACS selectively for dense cataracts or compromised endothelium, using fragmentation patterns that reduce energy [S3] [S5] [S8].
• Audit laser-specific complications such as incomplete capsulotomy and tags [S1].

Refer when

Pitfalls

• Claiming better vision or safety from FLACS for routine cases [S2] [S6].
• Ignoring cost: the ICER per QALY was £167,620 in FACT [S2].
• Using laser arcuate keratotomy instead of a toric IOL when one is available [S7].
• Overlooking anterior capsule tags and incomplete capsulotomy [S1].

Evidence notes

• In the Cochrane review, 16 studies had financial links with the laser manufacturer, and 13 paired-eye studies were analysed ignoring the pairing [S6].
• FACT was publicly funded (NIHR HTA) and outcome-masked, but participants were not masked [S2].
• Sources conflict on anterior capsule tears ([S1] vs [S6]) and on long-term acuity ([S9] vs [S10]); the larger and more recent syntheses [S6] [S10] show no meaningful difference.
• Not covered by these sources: FLACS in low-income settings, paediatric or traumatic cataract, and comparison with MSICS.

Related articles

• Phacoemulsification: outcomes and techniques
• Manual small-incision cataract surgery

References

See the numbered source list below. Each marker [S#] links to its PubMed and DOI record.