Femtosecond laser-assisted cataract surgery (FLACS) uses ultrashort laser pulses to automate the most precision-dependent steps of cataract removal. Also called bladeless cataract surgery, it offers more precision than conventional phacoemulsification. It may be recommended for selected patients, particularly those receiving premium intraocular lenses.
Dr Shibal Bhartiya is a fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator with over 25 years of experience. Her approach focuses on identifying risk before damage is irreversible, simplifying treatment decisions, and protecting vision long-term. Emphasis on early detection, risk assessment, and continuity of care. She is rated 5 stars across 1,500+ patient reviews on Google.
What Is Femtosecond Laser-Assisted Cataract Surgery?
FLACS uses an infrared laser that fires in femtosecond pulses, each lasting one quadrillionth of a second. This pulse duration is short enough to create photodisruption in tissue without generating heat. The laser separates tissue cleanly and precisely, with no thermal damage to surrounding structures.
The laser automates three critical surgical steps. First, it creates the corneal incisions. Second, it performs the anterior capsulotomy, opening the lens capsule with a circular cut. Third, it fragments and softens the cataractous lens before the surgeon removes it. These steps replace the manual blade work and ultrasonic energy delivery of traditional phacoemulsification.
The system images the anterior segment in real time using optical coherence tomography. This allows the surgeon to plan and customise every incision before the laser fires. Nothing happens without surgeon review and approval.
How Does FLACS Differ from Conventional Cataract Surgery?
Conventional phacoemulsification uses a handheld ultrasonic probe to break up and remove the lens. The capsulotomy and corneal incisions are made manually with a blade. The technique is safe, effective, and remains the global standard of care.
FLACS achieves similar refractive and safety outcomes to conventional phacoemulsification in most patients. The difference lies in precision and reproducibility. The laser creates a capsulotomy that is more consistently circular, centred, and correctly sized than a manual tear. FLACS reduces the amount of phacoemulsification energy delivered by 33 to 70% by softening the lens before removal. Less ultrasonic energy in the eye means less stress on the corneal endothelium.
The major disadvantages of FLACS are the high cost of the laser and disposables, FLACS-specific intraoperative capsular complications, the risk of intraoperative miosis, and the learning curve.
Neither technique is universally superior. Patient selection determines which approach delivers the better outcome.
The Four Steps FLACS Performs
Anterior capsulotomy
The laser creates a perfectly circular opening in the lens capsule. Manual capsulotomy produces variable shapes and sizes even in experienced hands. A precisely centred, correctly sized capsulotomy improves IOL centration after implantation. This matters most when the patient receives a toric, multifocal, or extended depth-of-focus lens.
Lens fragmentation
The laser pre-softens and divides the cataractous lens into segments before the surgeon begins phacoemulsification. FLACS has the potential to reduce endothelial cell loss and improve postoperative outcomes by making critical surgical steps easier and safer. Dense cataracts require more ultrasonic energy to break up manually. Pre-fragmentation reduces that energy load.
Corneal incisions
The laser creates the main wound and side-port incision with programmable geometry. It can produce biplanar or triplanar wound configurations that self-seal more reliably than single-plane manual cuts. Wound architecture directly affects the risk of post-operative infection and astigmatic shift.
Arcuate keratotomy incisions
Where the patient has pre-existing corneal astigmatism, the laser can place precise relaxing incisions in the corneal periphery at the time of surgery. This reduces dependence on toric IOLs for mild astigmatism correction.
Who Benefits Most from FLACS?
FLACS adds the most clinical value in specific situations.
FLACS is beneficial in patients with low baseline endothelial cell count and those planning to receive multifocal intraocular lenses. PubMed Corneas with reduced endothelial reserve cannot tolerate high phacoemulsification energy. Pre-fragmentation with the laser reduces that energy exposure.
Premium IOL recipients benefit from the capsulotomy precision. Multifocal and EDOF lenses divide incoming light into multiple focal points. Even small errors in centration degrade optical quality. A laser-created capsulotomy reduces this risk.
Patients with dense or brunescent cataracts benefit from pre-fragmentation, which reduces surgical time and energy. Patients requiring astigmatism correction at the time of surgery benefit from laser arcuate incisions.
FLACS does not offer a clear advantage for routine, moderate-density cataracts in eyes with healthy corneas and standard IOL selection.
What to Expect During FLACS
The procedure has two phases.
In the first phase, the surgeon docks the laser handpiece to the eye and applies gentle suction. The OCT system images the anterior segment. The surgeon reviews and approves the treatment plan on screen. The laser fires and completes the capsulotomy, fragmentation, and incisions in under a minute. The suction is released.
In the second phase, the patient moves to the operating table. The surgeon completes phacoemulsification, removes the fragmented lens material, and implants the intraocular lens. This phase is identical to conventional cataract surgery.
Total time in the surgical suite is similar to conventional surgery. Recovery is the same.
FLACS and Glaucoma: What Patients Need to Know
The docking step raises intraocular pressure by approximately 15 to 20 mmHg during suction. This is transient and brief. In eyes with advanced glaucoma and a severely damaged optic nerve, this IOP spike warrants careful assessment.
Dr Bhartiya evaluates optic nerve status, pre-operative IOP control, and disc perfusion before recommending FLACS in any glaucoma patient. In end-stage disease, conventional surgery without docking is often the safer option.
Patients with mild to moderate glaucoma are not automatically excluded from FLACS. Individual assessment is required.
FLACS for Premium IOL Surgery in India
Demand for spectacle independence after cataract surgery is growing in India. Toric, multifocal, and EDOF lenses deliver excellent outcomes but require precise surgical technique. Capsulotomy centration and size directly affect how these lenses perform.
FLACS addresses this requirement. The laser-created capsulotomy is more reproducible than the best manual technique. For patients investing in premium lenses, this precision has real clinical value.
Dr Bhartiya discusses IOL selection and surgical approach at consultation, based on each patient’s visual requirements, corneal health, and lifestyle.
Read the research articles
This article was written by Dr Shibal Bhartiya, fellowship-trained glaucoma specialist and Mayo Clinic Research Collaborator, Clinical Director at Marengo Asia Hospitals, Gurugram, known for ethical, patient-centred glaucoma care and independent glaucoma second opinions. She is also the Program Director for Community Outreach & Wellness; and for the Marengo Asia International Institute of Neuro and Spine. This article was updated in April 2026.
She has published peer-reviewed research on glaucoma management, examining how treatment decisions should balance medical evidence, patient preferences, and long-term vision outcomes.
As Editor-in-Chief of Clinical and Experimental Vision and Eye Research and Executive Editor of the Journal of Current Glaucoma Practice (Pubmed Indexed, official journal of the International Society of Glaucoma Surgery), Dr Shibal Bhartiya brings editorial and research depth to every clinical decision. Her 200+ publications, including 90+ PubMed-indexed publications and 28 edited textbooks span glaucoma biology, surgical outcomes, health equity, and emerging diagnostics.
Access her work on Pubmed, Google Scholar, ResearchGate and ORCID.
Dr Shibal Bhartiya
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