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Cataract Editorial Femtosecond Laser-assisted Cataract Surgery— Challenging Cases, Successes, and Complications Mark Packer, MD, FACS, CPI Medical Director, BoulderEyes, Boulder, Colorado, US; Clinical Associate Professor, Oregon Health and Science University, Oregon, US Abstract While femtosecond laser-assisted cataract surgery (FLACS) is evolving as an alternative to phacoemulsification, there are a lack of data on its use in challenging cases. This article discusses cases in which FLACS is particularly advantageous including subluxated cataracts, prior eye surgery, combined vitrectomy and FLACS, pediatric cataract surgery, small pupils, and nanophthalmos. However, FLACS does not produce superior outcomes in all cases and caution is needed in cases of posterior polar cataracts, glaucoma, and prior use of silicone oil. Keywords FLACS, challenging cases, complications Disclosure: Mark Packer, MD, FACS, CPI, is a consultant to Alcon Laboratories (Novartis AG) and Bausch & Lomb (Valeant Pharmaceuticals International, Inc.), and is consultant to and has equity in Lensar, Inc. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. Received: February 17, 2015 Accepted: February 18, 2015 Citation: US Ophthalmic Review, 2015;8(1):19–20 Correspondence: Mark Packer, MD, FACS, CPI, 1400 Bluebell Ave, Boulder, Colorado, US. E: mark@markpackerconsulting.com Support: Editorial assistance was provided by Katrina Mountfort, PhD, from Touch Medical Media, London, UK, funded by Touch Medial Media. The last few years have seen a deluge of publications discussing the potential advantages of femtosecond laser-assisted cataract surgery (FLACS) compared with traditional phacoemulsification, but its introduction has been controversial. While many consider that the technique will transform cataract surgery, others claim it is not cost-effective and offers no significant advantages over traditional techniques. In routine cases, FLACS has been shown to be comparable or superior to manual phacoemulsification. 1,2 On the other hand, in difficult and challenging cases, FLACS may offer new opportunities for success. The quality of the capsulotomies associated with FLACS, 3 together with the reduction in the time and energy required for ultrasound fragmentation of the cataract, 4 suggest that the technique may be of value in high-risk, complex clinical cases. However, the major clinical trials investigating the efficacy and safety of FLACS have had strict exclusion criteria, and details of its use in challenging cases have only recently begun to emerge. This review discusses areas of promise as well as cases requiring caution. FLACS has been associated with decreased endothelial cell loss, 5 an important consideration in cataract surgery after corneal transplant because postoperative transplant cell counts are lower than those of normal corneas. FLACS has been successfully applied to an eye that had a previous penetrating corneal transplant, 6 and may be beneficial in other conditions causing low preoperative endothelial cell values or at higher risk for endothelial cell loss (e.g. endothelial dystrophy, diabetes, the elderly). Tou ch MEd ica l MEdia Questions have been raised about the safety of FLACS in patients that have had prior surgery. Cataract surgery in an eye that has had a prior vitrectomy can be challenging because the absence of the vitreous can lead to anatomic abnormalities, such as a deep anterior chamber and less support of the crystalline lens. Vitrectomy and concurrent FLACS is a safe and effective procedure that offers advantages compared with conventional procedures. 7,8 Prior refractive surgery, including laser- assisted in situ keratomileusis (LASIK) and radial keratotomy (RK), has not been associated with any flap complications or wound leak in FLACS. 9,10 Pediatric cataract surgery has a relatively high rate of complications, partly due to the elasticity of the capsule in young eyes. However, the femtosecond laser has potential to perform a circular, well-centered capsulotomy in these cases, and researchers in Germany have successfully performed FLACS anterior and posterior capsulotomies on infants. 11 In another instance of likely capsular complications, FLACS anterior capsulotomy with adjunctive use of a modified capsular tension ring has succeeded in a child with Marfan syndrome. 12 Cataracts resulting from trauma present significant challenges to the ophthalmic surgeon. Cataract surgery in white or hypermature cataracts has been associated with increased risk for incomplete capsulorhexis, posterior capsule rupture, endothelial cell loss, and incision complications, such as wound burn. 7 FLACS has been successfully employed in cases 19