Femtosecond Laser Assisted Cataract Surgery | David Richardson, MD

Femtosecond Laser Assisted Cataract Surgery |  David Richardson, MD


So today’s topic is going to be on Femtosecond
Laser Cataract Surgery also known as FLACS. In particular, we’re going to be discussing
whether or not the literature supports the marketing. First of all, can I have a show of hands how
many are familiar with FLACS? Ok, very good. How many of you have been to a presentation
on it already? Ok, so just a few. So, first, just a couple statements about
me; So you’ll understand a little bit about me and my practice. As well as why I’m here talking about this
particular conversation or topic… Cataract surgery is actually one of the focuses
of (not only my practice but) my career and not just in terms of performing it but also
in terms of educating those [patients] about it. For example, I wrote a book about cataracts
surgery. It was focused specifically for patients addressing
their needs, their concerns, and helping them to choose among the numerous options that
are now available. Because it’s not like it used to be decades
ago, as we know, where you just have a cataract, put in your lens, you’re done! He gets new glasses. Now, we know we have a lot of different lens
options. And now, there’s this type of surgery option
available: Laser-Assisted Cataract Surgery (we’ll talk about that). As a doctor who’s in private practice, I
also spend, on average, between 45 and 60 minutes with my new cataract surgery consultations. And that’s because, I think, it’s really
important to actually communicate all of these very, very confusing topics to patients and
that just cannot be done in a short period of time. And finally, as Adjunct Assistant Professor
of Clinical Ophthalmology of USC [University of Southern California]. My primary role there is teaching residents
how to communicate these things to their patients in the clinic as well as developing the skill
sets they need in the operating room. I have no conflicts of interest. This is important to be aware of. With each presentation that you get on something
that’s going to cost your patients hard-earned money. This will not be your typical industry-sponsored
dinner talk which just glosses over the side effects and counts all of the benefits. I want you to have a clear understanding of
what the literature states. What is laser cataract surgery? Well that’s a misnomer and we do not perform
cataract surgery with a laser. It’s not been done and it’s still not. What it is, in fact, is Femto Laser Cataract
Surgery also known as FLACS. The “Femto” is short for “Femtosecond”. This is the same laser that’s used very
successfully with lasik. Instead of using the microkeratome, you use
a laser. It cuts to clear tissues such as the cornea
very, very well; and very precisely. And that particular term is one that you will
be exposed to (if you’ve not already been exposed to)
Precision. One of the things that the marketing pushes
about the femto laser-assisted cataract surgery (I’m just going to call it FLACS from now
on) is that it’s more precise than manual or the traditional, ultrasound-only phacoemulsification. Precision is a term that, you have to recognize,
comes with a lot of assumed promises. And we’re going to discuss whether or not
assumed promises are actually born out. Can I just get an idea, when you hear the
word, “precise” when discussing cataract surgery, what are some of the things that
you think that might be describing? Any ideas? Capsulorhexis – precision in creating the
Capsulorhexis. What other things do we look for with precision? What the patients’ ultimately want after
surgery? Better vision – closer to 20/20; closer
to 20/20 uncorrected. So, if we can get something that could accurately
get somebody there that would be very desirable. So precision is being used very loosely in
marketing and advertising to make us feel like we’re going to get our patients closer
to 20/20. That’s the assumed promise. So let’s see whether or not that’s actually
the case. Other marketing terms you’ll hear: Safer. When you hear, “safer” what do you think? What do your patients think when they hear
“safer”? Less side effects. Less risks. Let’s see whether that’s the case. The other thing you’re going to see: Gentler. “Laser is gentler than ultrasound”. Again, “gentler”, one would think, is
safer. Fewer risks. What Does the Laser Do? So let’s take a look. Just briefly for those who aren’t aware. What does this laser do? Create Corneal Incisions – It makes incisions. Corneal incisions – the side port incision,
the main incision. You can also make arcuate incisions. So limbal relaxing incisions to correct for
astigmatism. Now, traditionally we do these with metal
or diamond keratomes but they can be done with a laser now. Create an opening in the Capsular Bag – You
mentioned creation of the capsulorhexis. The laser can create a perfectly round capsulorhexis
and it is beautiful. When you watch this laser performing capsulorhexis,
it is perfectly round. The question is, “does it matter?” Now, traditionally we perform the capsulorhexis
with either forceps or *** bent needle cystotome. Soften the Cataract – The other thing you
can do is soften the cataract. Well softening the cataract makes sense because
you can soften the cataract before using ultrasound energy. You’ll use less ultrasound energy. Less ultrasound energy should protect the
corneal endothelium, should result in less inflammation, faster healing and just generally
a gentler procedure. So this is where the term, “gentler” comes
from. Now, you can also soften the cataract using
certain phacoemulsification techniques, such as “chopping”, which is a newer technique;
it’s more challenging technique but it’s one that most surgeons should be capable of
performing and chopping essentially does the same thing as the laser softening. So, what does the laser do? The summary is, “nothing that can’t be
done already hasn’t been done already”. So, the real question is, “is using a laser
to perform these things truly superior to the ultrasound only” And the marketing tells
you that it is. And indeed (if I was to present the industry
supported marketing) it looks pretty slick. But, we only have about 20 minutes today so
rather than show you all of that, which you can find very easily and I personally don’t
believe it because it’s industry-supported (he who pays the piper chooses the song /chooses
the outcome of what’s going to be published). I find that literature to be very questionable. So, I’ve chosen instead to present to you
the literature that you’re not going to get presented at any industry-supported evening
dinner show; the peer-reviewed large studies that were performed by non-industry-supported
groups. This is an expression of my disappointment
(as well as others disappointments) when we realized that, “Wow! There’s really nothing that the laser does
that we can’t do already. It just does it in a way that sounds a lot
cooler.” So let’s take a look here. This is a Peter Barry, MD († 2016) who presented
the preliminary results of a study performed by the European Society of Cataract and Refractive
Surgery. And I’d like to thank my colleague Dr. Steven
Safran in New Jersey who brought many of these studies to my attention as I was investigating
whether or not this was something that I wanted to provide to my patients. So this study was not a small study there
are 16 centers in 10 European countries throughout Europe. This involved almost 3,000 patients. So what were the results? Worse post-operative visual acuity – Unfortunately,
the visual acuity, which we were hoping precision would result in better acuity, (it) turns
out that in this study those who had FLACS actually ended up with worse visual acuity
on average than those who had phacoemulsification only. Now it was small but still it was worse and
whole point is we believe the marketing that it should be better but it was not. More post-operative complications – It gets
gets worse. there were more postoperative complications
among those who underwent FLACS than those who underwent standard phacoemulsification. Were more likely to have post-op visual acuity
worse than pre-op – Take a look at this. This requires that we spend a moment and think
about it. Those who underwent FLACS were more likely
to have post-op visual acuity that was worse than pre-op. Why do we submit our patients to the risk
of surgery? To make their vision better. Any new technique or technology has to, at
the very least, not make patients worse more often than the gold standard. So FLACS fails there. Let’s take a closer look and because these
these results are really unintuitive right? So let’s first take a look at the idea of
accuracy. Again, what is being loosely referred to with
the marketing term, “precision”. One would think that if you’re targeting
plano refractive error or minus one-half (whatever it is you’re targeting), that this more
advanced technology is going to get you closer to your target. Well, indeed, that’s not the case. At least not based on the preliminary results
of this very, very large study. Postoperative Surgical Complications I think
it’s important to look at the types of complications that are more common. Corneal Edema, Posterior Capsule Opacification,
and uveitis (so anterior chamber reaction) ***. These are not small differences. In fact, corneal edema is five times more
likely among those who had FLACS; Posterior Capsule Opacification, six times more likely. Now you may say, “Okay that’s not a big
deal. We take them back to the the yag laser. Good to go!” The yag laser is not without risk. Specially in high myopes. Three times the risk of anterior chamber reaction. “Ok”, you say “but that’s just one
study”. Albeit a very large study – almost 3,000
patients. Well it’s not the only study. There’s another study that looked at almost
2,000 patients enrolled and what this one found and I’ll read the conclusions because
it’s a little difficult for you see, “femtosecond laser cataract surgery did
not demonstrate clinically, meaningful improvement in visual outcomes over conventional phacoemulsification
cataract surgery.” If you look up a little bit higher it gets
even more concerning. “Phacoemulsification cataract surgery cases
had more letters gained compared with laser cataract surgery.” So conventional, actually, did better. And why that might have been the case? Well let’s look again at risks and complications. Perioperative Complications – laser cataract
surgery and phacoemulsification only. If you take a look at those ring in the red
you’ll see that there are some significant differences but not just your usual, just
barely, less than P (P-Value) or P is less than 0.05 these are really statistically significant. But more important than statistically significant
they are clinically significant. Ocular hypertension, cystoid macular edema
– these are things that can result in loss of vision. It should be noted that these are not the
first studies to show this cystoid macular edema is an increased risk in FLACS. This study is from 2014 and showed an increased
risk of cystoid macular edema in cataract surgery patients who underwent FLACS. So why might this be? What could be going on during the laser portion
of FLACS that results in (more likely) corneal edema, increased anterior chamber reaction,
iop elevation, cystoid macular edema and posterior capsule opacification. What could be the the unifying factor here? Well, let’s take a look at some of the studies
that have actually looked at the changes that occur during and after the femto laser portion
of the cataract surgery. So with corneal edema, what could be going
on? Well it turns out that the bubbles that occur
(the cavitation bubbles that occur) from the femtosecond laser change the pH in the aqueous. It shifts it to more acidic aqueous. And we know that the corneal endothelium is
exceptionally sensitive to changes in pH. Anterior Chamber Reaction – Prostaglandins
have been shown to rise immediately after femtosecond laser treatment. Prostaglandins are part of the pro-inflammatory
cascade. But that’s not it. It’s not just the prostaglandins. There are, in addition, other inflammatary
mediators that have been shown to increase after the femto portion of the cataract surgery
(Increase inflammatory Cytokines after Femto treatment). Posterior Capsular Opacification – How about
Posterior Capsular Opacification? Well, It turns out that femto is association
with a higher concentration of fibroblast growth factor as well as other pro fibrotic
factors. The conclusion from that particular paper
was “femtosecond laser pretreatment in cataract
surgery significantly induces altered levels of pro-fibrotic intraocular cytokines which
are involved in the development PCO…Increased levels of these cytokines and growth factors
in aqueous humor in the early phase after cataract surgery could induce lens epithelial
cell proliferation, migration and transdifferentiation.” So today’s topic is going to be on Femtosecond
Laser Cataract Surgery also known as FLACS. In particular, we’re going to be discussing
whether or not the literature supports the marketing. First of all, can I have a show
of hands how many are familiar with FLACS? Ok, very good. How many of you have been to
a presentation on it already? Ok, so just a few.
So, first, just a couple statements about me; So you’ll understand a little bit about
me and my practice. As well as why I’m here talking about this particular conversation
or topic… Cataract surgery is actually one of the focuses of (not only my practice but)
my career and not just in terms of performing it but also in terms of educating those [patients]
about it. For example, I wrote a book about cataracts
surgery. It was focused specifically for patients addressing their needs, their concerns, and
helping them to choose among the numerous options that are now available. Because it’s
not like it used to be decades ago, as we know, where you just have a cataract, put
in your lens, you’re done! He gets new glasses. Now, we know we have a lot of different lens
options. And now, there’s this type of surgery option available: Laser-Assisted Cataract
Surgery (we’ll talk about that). As a doctor who’s in private practice, I
also spend, on average, between 45 and 60 minutes with my new cataract surgery consultations.
And that’s because, I think, it’s really important to actually communicate all of these
very, very confusing topics to patients and that just cannot be done in a short period
of time. And finally, as Adjunct Assistant Professor
of Clinical Ophthalmology of USC [University of Southern California]. My primary role there
is teaching residents how to communicate these things to their patients in the clinic as
well as developing the skill sets they need in the operating room.
I have no conflicts of interest. This is important to be aware of. With each presentation that
you get on something that’s going to cost your patients hard-earned money. This will
not be your typical industry-sponsored dinner talk which just glosses over the side effects
and counts all of the benefits. I want you to have a clear understanding of what the
literature states. What is laser cataract surgery? Well that’s
a misnomer and we do not perform cataract surgery with a laser. It’s not been done
and it’s still not. What it is, in fact, is Femto Laser Cataract Surgery also known
as FLACS. The “Femto” is short for “Femtosecond”.
This is the same laser that’s used very successfully with lasik. Instead of using
the microkeratome, you use a laser. It cuts to clear tissues such as the cornea very,
very well; and very precisely. And that particular term is one that you will be exposed to (if
you’ve not already been exposed to) Precision. One of the things that the marketing
pushes about the femto laser-assisted cataract surgery (I’m just going to call it FLACS
from now on) is that it’s more precise than manual or the traditional, ultrasound-only
phacoemulsification. Precision is a term that, you have to recognize, comes with a lot of
assumed promises. And we’re going to discuss whether or not assumed promises are actually
born out. Can I just get an idea, when you hear the
word, “precise” when discussing cataract surgery, what are some of the things that
you think that might be describing? Any ideas? Capsulorhexis – precision in creating the
Capsulorhexis. What other things do we look for with precision? What the patients’ ultimately
want after surgery? Better vision – closer to 20/20; closer to 20/20 uncorrected. So,
if we can get something that could accurately get somebody there that would be very desirable.
So precision is being used very loosely in marketing and advertising to make us feel
like we’re going to get our patients closer to 20/20. That’s the assumed promise. So
let’s see whether or not that’s actually the case.
Other marketing terms you’ll hear: Safer. When you hear, “safer” what do you think?
What do your patients think when they hear “safer”? Less side effects. Less risks.
Let’s see whether that’s the case. The other thing you’re going to see: Gentler.
“Laser is gentler than ultrasound”. Again, “gentler”, one would think, is safer.
Fewer risks. What Does the Laser Do? So let’s take a
look. Just briefly for those who aren’t aware. What does this laser do?
Create Corneal Incisions – It makes incisions. Corneal incisions – the side port incision,
the main incision. You can also make arcuate incisions. So limbal relaxing incisions to
correct for astigmatism. Now, traditionally we do these with metal or diamond keratomes
but they can be done with a laser now. Create an opening in the Capsular Bag – You
mentioned creation of the capsulorhexis. The laser can create a perfectly round capsulorhexis
and it is beautiful. When you watch this laser performing capsulorhexis, it is perfectly
round. The question is, “does it matter?” Now, traditionally we perform the capsulorhexis
with either forceps or *** bent needle cystotome. Soften the Cataract – The other thing you
can do is soften the cataract. Well softening the cataract makes sense because you can soften
the cataract before using ultrasound energy. You’ll use less ultrasound energy. Less
ultrasound energy should protect the corneal endothelium, should result in less inflammation,
faster healing and just generally a gentler procedure. So this is where the term, “gentler”
comes from. Now, you can also soften the cataract using certain phacoemulsification techniques,
such as “chopping”, which is a newer technique; it’s more challenging technique but it’s
one that most surgeons should be capable of performing and chopping essentially does the
same thing as the laser softening. So, what does the laser do? The summary is,
“nothing that can’t be done already hasn’t been done already”. So, the real question
is, “is using a laser to perform these things truly superior to the ultrasound only” And
the marketing tells you that it is. And indeed (if I was to present the industry supported
marketing) it looks pretty slick. But, we only have about 20 minutes today so rather
than show you all of that, which you can find very easily and I personally don’t believe
it because it’s industry-supported (he who pays the piper chooses the song /chooses the
outcome of what’s going to be published). I find that literature to be very questionable.
So, I’ve chosen instead to present to you the literature that you’re not going to
get presented at any industry-supported evening dinner show; the peer-reviewed large studies
that were performed by non-industry-supported groups.
This is an expression of my disappointment (as well as others disappointments) when we
realized that, “Wow! There’s really nothing that the laser does that we can’t do already.
It just does it in a way that sounds a lot cooler.”
So let’s take a look here. This is a Peter Barry, MD († 2016) who presented the preliminary
results of a study performed by the European Society of Cataract and Refractive Surgery.
And I’d like to thank my colleague Dr. Steven Safran in New Jersey who brought many of these
studies to my attention as I was investigating whether or not this was something that I wanted
to provide to my patients. So this study was not a small study there
are 16 centers in 10 European countries throughout Europe. This involved almost 3,000 patients.
So what were the results? Worse post-operative visual acuity – Unfortunately,
the visual acuity, which we were hoping precision would result in better acuity, (it) turns
out that in this study those who had FLACS actually ended up with worse visual acuity
on average than those who had phacoemulsification only. Now it was small but still it was worse
and whole point is we believe the marketing that it should be better but it was not.
More post-operative complications – It gets gets worse. there were more postoperative
complications among those who underwent FLACS than those who underwent standard phacoemulsification.
Were more likely to have post-op visual acuity worse than pre-op – Take a look at this.
This requires that we spend a moment and think about it. Those who underwent FLACS were more
likely to have post-op visual acuity that was worse than pre-op. Why do we submit our
patients to the risk of surgery? To make their vision better. Any new technique or technology
has to, at the very least, not make patients worse more often than the gold standard. So
FLACS fails there. Let’s take a closer look and because these
these results are really unintuitive right? So let’s first take a look at the idea of
accuracy. Again, what is being loosely referred to with the marketing term, “precision”.
One would think that if you’re targeting plano refractive error or minus one-half (whatever
it is you’re targeting), that this more advanced technology is going to get you closer
to your target. Well, indeed, that’s not the case. At least not based on the preliminary
results of this very, very large study. Postoperative Surgical Complications I think
it’s important to look at the types of complications that are more common.
Corneal Edema, Posterior Capsule Opacification, and uveitis (so anterior chamber reaction)
***. These are not small differences. In fact, corneal edema is five times more likely among
those who had FLACS; Posterior Capsule Opacification, six times more likely.
Now you may say, “Okay that’s not a big deal. We take them back to the the yag laser.
Good to go!” The yag laser is not without risk. Specially in high myopes. Three times
the risk of anterior chamber reaction. “Ok”, you say “but that’s just one study”.
Albeit a very large study – almost 3,000 patients. Well it’s not the only study.
There’s another study that looked at almost 2,000 patients enrolled and what this one
found and I’ll read the conclusions because it’s a little difficult for you see,
“femtosecond laser cataract surgery did not demonstrate clinically, meaningful improvement
in visual outcomes over conventional phacoemulsification cataract surgery.”
If you look up a little bit higher it gets even more concerning.
“Phacoemulsification cataract surgery cases had more letters gained compared with laser
cataract surgery.” So conventional, actually, did better. And
why that might have been the case? Well let’s look again at risks and complications.
Perioperative Complications – laser cataract surgery and phacoemulsification only. If you
take a look at those ring in the red you’ll see that there are some significant differences
but not just your usual, just barely, less than P (P-Value) or P is less than 0.05 these
are really statistically significant. But more important than statistically significant
they are clinically significant. Ocular hypertension, cystoid macular edema – these are things
that can result in loss of vision. It should be noted that these are not the first studies
to show this cystoid macular edema is an increased risk in FLACS.
This study is from 2014 and showed an increased risk of cystoid macular edema in cataract
surgery patients who underwent FLACS. So why might this be? What could be going on during
the laser portion of FLACS that results in (more likely) corneal edema, increased anterior
chamber reaction, iop elevation, cystoid macular edema and posterior capsule opacification.
What could be the the unifying factor here? Well, let’s take a look at some of the studies
that have actually looked at the changes that occur during and after the femto laser portion
of the cataract surgery. So with corneal edema, what could be going
on? Well it turns out that the bubbles that occur (the cavitation bubbles that occur)
from the femtosecond laser change the pH in the aqueous. It shifts it to more acidic aqueous.
And we know that the corneal endothelium is exceptionally sensitive to changes in pH.
Anterior Chamber Reaction – Prostaglandins have been shown to rise immediately after
femtosecond laser treatment. Prostaglandins are part of the pro-inflammatory cascade.
But that’s not it. It’s not just the prostaglandins. There are, in addition, other inflammatary
mediators that have been shown to increase after the femto portion of the cataract surgery
(Increase inflammatory Cytokines after Femto treatment).
Posterior Capsular Opacification – How about Posterior Capsular Opacification? Well, It
turns out that femto is association with a higher concentration of fibroblast growth
factor as well as other pro fibrotic factors. The conclusion from that particular paper
was “femtosecond laser pretreatment in cataract
surgery significantly induces altered levels of pro-fibrotic intraocular cytokines which
are involved in the development PCO…Increased levels of these cytokines and growth factors
in aqueous humor in the early phase after cataract surgery could induce lens epithelial
cell proliferation, migration and transdifferentiation.” So this is a a posited mechanism by which
Posterior Capsule Opacification (PCO) could actually be more likely after Femto. It’s
a reasonable hypothesis. So then where does this leave us with regard
to FLACS versus traditional, ultrasound-only phacoemulsification? Well, first of all, let’s
take a look at the benefits. I mean, the marketing benefits don’t seem to have a lot of support
in the literature. At least not in the non-industry supported, large-scale population studies.
You have to admit it’s cool. I mean, it is a really cool technology. Anytime you have
laser and you put it with anything it just makes things cooler. And this is very much
true with patients they hear laser cataract surgery and they want it.
It’s fun for the surgeon And it is a lot of fun for the surgeon. Okay, Ophthalmologists,
in general, are kind of geeky. We like our Star Wars and most of us have seen Logan’s
Run and there’s something about doing surgery with a laser – it just…it feels cool.
And I will say – having performed FLACS, it is fun. There’s just something about
watching that video screen…it turns surgery into a video game. And so from the surgeons
perspective, it’s a lot of fun. It does give bragging rights to the patient.
The patients get to tell their friends at the golf course/at cocktail parties that they
had laser cataract surgery. Right? And that really does sound impressive. Even more so
when you find out that in general we have to pay extra for it. So, it’s kind of like
“anything that have to pay extra for – whether it be a nice bag or a really nice car, whatever
it is, you get bragging rights for it. But,…To date there’s no strong evidence
from (this is key to recognize) independent (non-industry supported), peer-reviewed (published
and represented in major conferences). So, no strong evidence from independent, peer-reviewed
studies, supporting an objective benefit. Not just a cool sounding marketing term benefit,
like “precision”, which basically means “nothing clinically”. But, an objective
benefit to patients of FLACS over conventional phacoemulsification.
But it gets worse. FLACS appears to actually be associated with greater pro-inflammatory
changes in the aqueous humor that can lead to increased risks of vision-threatening postoperative
complications including: corneal edema, anterior chamber reaction, cystoid macular edema, posterior
capsule pacification, and intraocular pressure elevation.
And I’ve not spoken about any of the other risks that were common in the early studies
of Femto; such as capsular tags, increased risk of posterior capsule rupture, and things
that were largely associated with learning curves of the surgeon or with improvements
in technology. We’ve not talked about those because, I think that for the most part, those
were related to learning curves and technology issues that have, for the most part, been
solved. So, what I wanted to focus on today was just what (objectively) appears to be
going on when you look at a large number of patients who’ve had surgery by experienced
surgeons with the modern equipment that’s available. All of the FLACS have been modern,
but [I mean] the most recent. Still despite everything that I said today,
FLACS is very much in its infancy. There’s a very, very good possibility that with tweaks
to the technology – perhaps the hardware, perhaps the software, or perhaps changes in
the way we treat patients pharmacologically (so either with with drops or injections before
or during surgery), that it may be possible (we may be able to) reduce or even eliminate
the rise inflammatory mediators and with that the added risks of FLACS. So that FLACS could
potentially – not only be “equivalent” to ultrasound-only phacoemulsification, but
“better than”. To summarize, at the moment…
FLACS is not all it’s stouted to be. Not by any objective criteria
At the moment there is no strong evidence that FLACS is superior to conventional phacoemulsification,
and may actually be a step back at least with regard to intraocular inflammation and its
associated risks and complications. But (I do think that there’s the real possibility
that) with advances in technology, it may have the potential to make good on at least
some of its promises. That’s just not the case yet.
My argument is that until that’s the case it’s very very difficult for me, as a surgeon,
to justify strongly recommending FLACS to my patients over traditional phacoemulsification-only
surgery because I don’t think that the coolness factor and that the bragging rights really
justifies the risks that I just went over. Anyway, that’s my view. You will definitely
hear alternative views but I want to thank you for attending this and then now it’s
off to lunch. Any questions that anyone has? All right, thank you.

5 thoughts on “Femtosecond Laser Assisted Cataract Surgery | David Richardson, MD

  • Our numerous peer-reviewed clinical trials were prospective randomized clinical trials and new techniques (including LCS pediatric cataract surgery or minicapsulotomy)and were  WITHOUT ANY COMPANY SUPPORT and are not mentioned all in this unbalanced presentation at all. From my point of view this is not a neutral well-balanced talk at all. Too sad.

  • I am thinking of having cataract surgery, have there been any technology gains made in the last year that have made Flacs safer?

  • my surgeon said that flacs would be better in my case since the cataract is advanced, but im not sure yet if manual would work out just as good

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