As cataract surgery becomes increasingly precise and customizable, ambulatory surgery centers (ASCs) face the challenge of determining which technologies both meaningfully enhance care and make sense from an operational and financial standpoint. Femtosecond laser-assisted cataract surgery (FLACS) is one such technology, offering potential advantages in reproducibility, astigmatism management, and complex cases while adding another layer to ASC workflow and costs.

For Luke Rebenitsch, MD, the value of FLACS today is closely tied to the broader evolution of premium cataract surgery. Here, Dr. Rebenitsch shares his perspective on where FLACS provides the greatest clinical value, how ASCs can incorporate the technology without sacrificing efficiency, and the financial and operational considerations that should guide its use.

The Ophthalmic ASC: How has your approach to FLACS in an ASC evolved over time, and where do you believe it provides the greatest value today?

Luke Rebenitsch, MD: It's rare that I do FLACS anymore, but when I first came into practice, we did FLACS on everyone. We did 1,000 consecutive cases with FLACS. The reason I used it was because of the reproducibility and the automation. With the capsular “nubs” on the Lensar system, I was able to be sure that I had the proper toric alignment because of the iris registration. The capsulotomy was also consistent and the ideal size. I think that FLACS really shines in premium cataract surgery because that's what people demand. And, frankly, that's what the economics of cataract surgery demand now, too.

With declining reimbursements, it's not only a good idea or good business practice to offer premium cataract surgery; it's a necessity for any cataract/refractive practice to survive and thrive. So, although I don't believe that FLACS is inherently necessary for a premium product or premium practice, I think it is a nice addition and adds a certain safety and marketing allure for patients. Just the word “laser” alone is something that resonates with patients and is associated with precision and good outcomes.

Everyone wants laser-quality vision, laser precision, and so having this is not only a benefit to help with marketing and providing upgrades, but also it can provide a better outcome than what is standard in some cases. I would argue that there are other ways to do that, such as augmented reality—such as what Zeiss’s Callisto, Alcon’s Verion, and Leica’s TrueVision, are doing. Unless you are using iris registration of some kind, it’s going to be challenging to deliver results that are as consistent.    

Arcuate keratotomies (AKs) and limbal relaxing incisions (LRIs) are certainly a benefit, as well as optimization of standardization of where the incision is made. Also, studies have shown that the lenses are less likely to have pantoscopic tilt and decentration with consistent capsulotomies.¹ Although it's not necessarily clinically relevant in most monofocals, with multifocals, tilt is important because it will increase higher-order aberrations and increase the risk of patient dissatisfaction. Again, reproducibility and automation is really the name of the game for somebody who is willing to pay that extra amount. 

From a safety standpoint, I think there's a huge benefit for white cataracts, loose zonules—anything you can do to decrease the trauma to the capsule and the zonules. And so, in those more challenging cases, there is a significant benefit of FLACS over manual approaches.

OASC: What are the key workflow considerations for successfully integrating FLACS into a busy ambulatory surgery center without sacrificing efficiency or throughput? Can you share specific strategies your team has found effective?

LR: There are a number of ways to maintain, if not increase, efficiency. Some practices will employ allied health professionals such as physician assistants, or a resident or other physicians to fire the laser.

Other practices are able to apply FLACS in a sterile fashion. The Ziemer laser is probably one of the most commonly used in that sense, where the laser can still be used intraoperatively, and there doesn’t have to be a delay post laser. 

There's an inherent perception that FLACS can slow you down, and it certainly can without proper processes. Whether it's being done in a sterile fashion or preoperatively, turnover times can be diminished. Some surgeons apply a FLACS, go do another cataract surgery in another room, and then come back and do the first one. So there are a number of operational ways to either maintain or improve efficiency without impacting the patient experience and the outcome that is desired with FLACS.

OASC: Patient selection remains an important consideration for FLACS. Which patients are the best candidates, and are there clinical scenarios where you believe the technology offers distinct advantages over conventional cataract surgery?

LR: A white cataract where this can be used instead of a Trypan blue is certainly a significant benefit. It's also useful in eyes with loose zonules or a history of ocular trauma. I think where FLACS typically shines is in the premium patient that wants the premium outcome, or the one who doesn't want to have to have an enhancement—the one who wants absolute laser precision. Features such as iris registration, capsular nubs, and AKs or LRIs help optimize the final outcome. The days of saying that 0.75 D of residual cylinder is clinically OK are behind us, especially with multifocal IOLs.² Patients want not only 20/20; they want 20/15 and beyond. So, really dialing in the surgical plan with the help of FLACS is certainly what patients desire.

Of course, there are certain patients for whom you should not use this. There are some arguments that it may increase inflammation over a manual approach in some soft cataracts. I think that's overstated. Pupils that are too small are typically not the best candidates. There is still the risk of pupillary miosis, so it's recommended that NSAIDs be applied before the laser to decrease that risk.

OASC: From a practice management perspective, what operational and financial factors should ASC leaders evaluate when implementing or expanding a FLACS program, and what common pitfalls should they avoid?

LR: Incorporating FLACS into the ASC is not just a matter of wheeling it in and turning it on. It's more than just a click fee; you have to pay the capital cost. Many to most practices will finance this, and there's also the service cost, which can be significant.

And these lasers go down from time to time, so you need to have a workflow for when patients who are expecting a laser can no longer get a laser that day—whether it's rescheduling or making sure the informed consent process includes the possibility that the laser may not be available. Also, because this is an additional cost, whatever premium fee is charged to the patient needs to take all that into account. You cannot “charge for the laser,” but you can charge for astigmatic management. Making sure that nuance is clearly defined in your consent process and in your sales and counseling process is key; it's important to charge enough. Inflation is very real and the prices for premium surgery have increased, and it's very easy to let your prices stay the same or even go down and realize that your profitability is going down with it.

OASC: Looking ahead, how do you see the role of FLACS evolving alongside advances in IOL technology, imaging, digital guidance systems, and other innovations in cataract surgery, and what should ASCs be doing now to prepare for that future?

LR: The digital revolution is certainly under way, and there are so many companies that have invested in this. Everyone knows that reimbursements are going down and will likely continue to go down. What patients want, and what we need to survive, is a process that has a value proposition that patients want or are willing to pay for. Studies have shown that adoption rates for premium IOLs are on the rise, from 35.2% in 2016 to 42.6% in 2020.³ If patients are willing to upgrade to something, we need to be able to offer that something.

Automation, safety, outcomes, range of vision, quality of vision—all those are incredibly important. FLACS is certainly part of the “how.” It's most important however to understand why patients are willing to pay out of pocket. It's because they want better outcomes and they want a better experience. If the laser can't provide that, this is not something that practices should use. However, with modern FLACS, being able to optimize the experience, ideally increasing safety and final outcomes, is really going to be necessary for the future.

Adjustability, customization, and automation are certainly buzzwords now. With the advent of the Light-Adjustable Lens (LAL; RxSight), people are asking for it, whether they get the LAL or not. And whether adjustability is available with RxSight’s light delivery device or with an excimer laser, this should be available for anyone receiving premium surgery. I'm a strong believer in having an excimer laser as a backup because patients expect a premium outcome, and refractive misses will happen to any surgeon.

There's no perfect surgeon; there's no perfect surgery. Always know that even with FLACS, there's always a chance that enhancements may be needed in the future. Be sure to stand by your results because good and bad outcomes affect all of us. OASC

References 

1. Lee Y, Choi HI, Bae S, Chung HS, Kim JY, Lee H. Analysis of intraocular lens decentration and tilt after femtosecond laser-assisted cataract surgery using swept-source anterior optical coherence tomography. Heliyon. 2024;10(9):e29780. doi:10.1016/j.heliyon.2024.e29780

2. Núñez MX, Henriquez MA, Escaf LJ, et al. Consensus on the management of astigmatism in cataract surgery. Clin Ophthalmol. 2019;13:311-324. doi:10.2147/OPTH.S178277

3. Huang CY, Pu C, Hou CH. Premium intraocular lens adoption: insights from a national health insurance analysis. J Formos Med Assoc. 2025;124(8):706-711. doi:10.1016/j.jfma.2024.07.027

Luke Rebenitsch, MD, is a refractive surgeon and medical director of ClearSight LASIK & Lens in Oklahoma City, Oklahoma, and Plano, Texas. He specializes in advanced vision correction, including SMILE, LASIK, refractive lens exchange, and premium cataract surgery, with a focus on precision, outcomes, and patient experience. Dr. Rebenitsch has been recognized for both clinical and leadership excellence, including the American Academy of Ophthalmology Achievement Award. He serves as a consultant and speaker for Johnson & Johnson Vision, BVI Medical, Bausch + Lomb, STAAR Surgical, RxSight, and OSRX.