Femtosecond Laser Breakthroughs Steal the Show at ESCRS 2025

Precision isn’t the by-product anymore—it’s the whole point. ESCRS 2025 put femto in the driver’s seat.

Day 4 at the 43rd Congress of European Society of Cataract and Refractive Surgeons (ESCRS 2025) in Copenhagen had one clear star: the femtosecond laser. Three powerhouse chairs—Prof. Béatrice Cochener-Lamard (France), Dr. Vance Thompson (United States) and Prof. Graham Barrett (Australia)—set the tone, framing the day as more than incremental progress.

What unfolded felt like a generational leap: sleeker hardware, AI-driven planning, capsulotomy-fixated optics, real-time IOL power personalization and a corneal refractive revival that dared to put patient experience front and center.

The new shape of FLACS

Prof. Burkhard Dick (Germany) was first on stage and wasted no time reframing the narrative. Forget extinction, he said—femto platforms are evolving. He showcased a new generation of compact, mobile devices: battery-powered capsulotomy units that finish in seconds, move between ORs and integrate with biometric data to prevent wrong-eye treatments.

But it was his comment on pediatric cataract surgery that really brought the audience forward in their seats. “The femtosecond laser is a gift for pediatric cases,” he said, describing how elasticity formulas and posterior capsulotomies are turning once high-risk eyes into safer, cleaner cases.

With age-dependent elasticity mapped by the Bochum formula, centers can predict anterior/posterior capsulotomy sizing and implant in the bag without anterior vitrectomy, reducing retinal detachment and glaucoma risk.¹

The take-home: femto is morphing from a stand-alone pre-op room machine into an integrated, intra-suite microsystem—smaller, smarter, safer.

From hand tool to co-pilot

Practicing in Los Angeles with high-demand patients, Dr. Dagny Zhu (United States) was unapologetic. “I do use the femtosecond laser in basically 100% of my cases because I do value the precision that it provides,” she said matter-of-factly.

With the LENSAR Ally platform at her side, Dr. Zhu described a workflow that felt more “co-pilot” than “hand tool.” AI imaging doesn’t just grade cataract density—it chooses fragmentation patterns.

WATCH NOW: Boosting Surgical Flow and Patient Comfort with LENSAR ALLY® System

And where does “robotics” truly sit? Dr. Zhu placed femto in category 1–2 on the robotics spectrum—surgeon-in-the-loop, semi-autonomous guidance that reduces variance, not the surgeon.

Looking ahead, she previewed joystick telemanipulation that has already completed animal cataract models end-to-end. The interim future feels practical: no-fly zones, tremor damping and reaction times that machines execute in milliseconds, not human quarters of a second.²

Femto with complex cataracts

Then came Prof. Soon Phaik Chee (Singapore), who always makes complex cataracts look deceptively easy.

She unfurled a reel that would give most surgeons sweaty palms: intumescent whites threatening to split, posterior polars perched on thin ice, subluxated lenses dancing on zonular threads.

Yet with femto, her narration turned chaos into choreography. Capsulotomies were complete and simultaneous, fragmentations tailored to preserve view, epinuclei handled like fine silk, and vitreous prolapse neutralized with precision moves.

Her message was grounded but powerful: “With femto, uncertainty shrinks and predictability grows.” Suddenly, the impossible looks routine.

The adjustable IOL era

Dr. Ronald Krueger (United States) shifted focus to IOLs that evolve inside the eye. His highlight was femtosecond Refractive Index Shaping (RIS). “We can literally write corrections inside the acrylic—change sphere, add EDOF, even multifocality—and erase it by overlaying opposite phase patterns…and all that in just 40 seconds,” he explained.

He also spotlighted the Light Adjustable Lens (LAL), which keeps gaining fans. UV-tuned silicone optics (RxSight) once again showed why they’re winning converts. In multiple clinical series—including U.S. cohorts after corneal refractive surgery—92–98% of eyes hit within ±0.50 D. Adjustments start at 3–4 weeks, with blended vision protocols increasingly becoming the go-to in premium practice.³

Then came argon-laser-driven micro-actuation. The concept is deceptively simple but potentially disruptive: use targeted argon heating to flex peripheral “springs” embedded in the IOL, allowing surgeons to nudge the effective lens position or fine-tune toric axis alignment after implantation.

No femtosecond writing, no UV tuning—just precision, on demand. The technology is now moving from concept into human trials, with the promise of making IOL adjustment less about prediction and more about post-operative personalization.

Capsulotomy as a fixation point

Prof. Gerd Auffarth (Germany) turned heads with capsulotomy-fixated IOLs like Teleon Surgical’s (Spankeren, The Netherlands) FEMTIS. In a 336-eye multicenter series, capsulotomy-hung optics showed dramatically less decentration, tilt and rotation than conventional bag-fixated C-loop designs—sub-0.1 mm mean decentration, with toric rotation “extremely low.”⁴

Yes, there’s a learning curve to flick the two main tabs over the rhexis and tuck the side wings, but once learned, it adds a minute or two. The payoff? If the posterior capsule ruptures, a multifocal can still be fixed in the anterior capsule.

“The capsulotomy is no longer just a circle—it becomes the load-bearing scaffold of refractive predictability,” he concluded.

Toric alignment: from overlays to on-optic landmarks

Prof. Sri Ganesh (India) compared limbal vessel–based overlays with an iris-registration, femto-based approach that carves two tiny “nubs” on the capsulotomy at the steep axis.

Those nubs become immutable, parallax-free landmarks at the IOL plane—align the toric marks to the nubs and you’re done, and you can verify alignment post-op by simply dilating and looking.

In a prospective comparison, both systems were safe and equally effective, but the iris-registration/nub method showed a lower mean deviation from the intended axis (≈2.8° vs ≈4.2°) and a higher proportion within 5°.⁵

“Irides don’t shift the way conjunctival vessels do,” he said, stressing reliability when overlays fail in messy reality.

Add automatic cyclotorsion compensation and SIA-aware incision planning and the capsulotomy itself becomes your resilient, lifelong coordinate system.

Second-generation KLEx wins the patient experience

Assoc. Prof. Marcus Ang (Singapore) zoomed out from LASIK’s femto revolution to the flapless era of keratorefractive lenticule extraction (KLEx/SMILE-type procedures).

First-generation systems matched LASIK refractively but lagged on day-one “wow,” were more manipulation-heavy, and suffered from suction losses that tanked intraoperative experience.

Second-generation platforms have swung the pendulum: single-digit-second laser times, lower energy for cleaner interfaces (but “stickier” planes that surgeons learn to dissect), built-in centration tools for angle kappa and visual-axis targeting and live cyclotorsion control for astigmatism.

In his fellow-eye randomized work, patients rated the newer small-incision pathway as markedly more comfortable, largely because suction loss plummeted to near-zero.

The subtext was clear: we’ve reached the stage where patient experience—docking, comfort, speed—drives word-of-mouth adoption as much as the modulation transfer function (MTF) curves.⁶

Modern day uses of the femto for corneal surgery

Dr. Francis Mah (United States) walked the audience from history to cutting edge. “One of the challenges is to weigh the advantages of femtosecond against the obvious added costs,” he admitted.

He traced the evolution from early grafts to femtosecond laser–enabled keratoplasty (FLEK). Shapes like the top-hat and mushroom offered partial solutions, but the zigzag cut has become most popular for its smooth transitions, interlocking precision and stronger wound stability.

Beyond keratoplasty, femtosecond precision has transformed keratoconus treatment. Intacs (intrastromal corneal ring segments) channels created with lasers reduce complications, while newer approaches like CAIRS replace PMMA with donor tissue.

“All-Femto CAIRS, where both channels and segments are laser-created, is showing added efficiency, and crosslinking these tissue rings may offer greater long-term stability,” Dr. Mah said.

And he closed with urgency: “Corneal blindness remains one of the main causes of reversible visual morbidity. The femtosecond has given us a new tool to bridge corneal disease and refractive surgery.”

Femtosecond laser–assisted anterior keratoplasty

Dr. Mayte Ariño-Gutierrez (Spain) started with the “basics”, but her basics showed how a femtosecond laser–assisted anterior keratoplasty is reshaping practice.

Those “basics” revealed precision leaps. Manual trephination creates mismatched donor and recipient cuts. Femtosecond systems with OCT and planning software cut both from the epithelial side, delivering perfect alignment. Her favored mushroom configuration—wide superficially, narrow in depth—treats larger zones while lowering perforation risk.

The gains are real: faster recovery, better endothelial cell counts and fewer rejections. “So far, femto-DALK has demonstrated faster visual recovery, better endothelial cell counts, lower rejection rates and lower perforation risk,” she emphasized.

Challenges remain—longer prep times, need for clear tissue—but her conclusion was clear: femtosecond anterior keratoplasty is safer, more precise and the new gold standard.

The new femto playbook

On Day 4 of ESCRS 2025, “advance” felt like an understatement. Between handheld capsulotomies, AI-notched rhexis planning, capsulotomy-hung optics, and on-eye optical editing, femto isn’t chasing manuals anymore. It’s writing a different rulebook—one where precision is the point, not the by-product.

And if you squinted just right in the Bella Center’s bright lights, you could see the outline of cataract and corneal surgery for the next decade: smaller devices, smarter software, steadier optics, happier patients.

Editor’s Note: The 43rd Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2025) was held from 12-16 September in Copenhagen, Denmark. Reporting for this story took place during the event. This content is intended exclusively for healthcare professionals. It is not intended for the general public. Products or therapies discussed may not be registered or approved in all jurisdictions, including Singapore.

References

Dick HB, Schelenz D, Schultz T. Femtosecond laser-assisted pediatric cataract surgery: Bochum formula. J Cataract Refract Surg. 2015;41(4):821-8266.
Edwards TL, Xue K, Meenink HCM, et al. First-in-human study of the safety and viability of intraocular robotic surgery. Nat Biomed Eng. 2018;2:649-656.
Folden DV, Wong JR. Visual Outcomes of an Enhanced UV Protected Light Adjustable Lens Using a Novel Co-Managed, Open-Access Methodology. Clin Ophthalmol. 2022;16:2413-2420.
Auffarth GU, Friedmann E, Breyer D, et al. Stability and Visual Outcomes of the Capsulotomy-Fixated FEMTIS-IOL After Automated Femtosecond Laser-Assisted Anterior Capsulotomy. Am J Ophthalmol. 2021;225:27-37.
Kodavoor SK, Divya J, Dandapani R, Ramamurthy C, Ramamurthy S, Sachdev G. Randomized trial comparing visual outcomes of toric intraocular lens implantation using manual and digital marker. Indian J Ophthalmol. 2020;68(12):3020-3024.
Chung B, Ryu IH, Lee IS, et al. Clinical outcomes of the immediate reapplication of small-incision lenticule extraction without adjusting the surgical parameters after suction loss. Sci Rep. 2022;12(1):15973.