If you’ve been told you have a cataract, you may have already discovered that “cataract surgery” isn’t a single, identical procedure for everyone. There are three main ways surgeons remove a cloudy lens today: phacoemulsification (often shortened to “phaco”), femtosecond laser-assisted cataract surgery (FLACS), and extracapsular cataract extraction (ECCE). Each has its own strengths, ideal use-cases, and practical considerations. In this guide, I’ll walk you through all three—plain-spoken, step by step—so you can understand what’s happening to your eye and why a particular approach might be recommended for you.
Think of this as your one-stop briefing before any deeper chat with your surgeon. By the end, you’ll know how the operations differ, what the theatre experience feels like, how recovery tends to unfold, and the sorts of lenses that can be implanted regardless of which method is used.
Quick orientation: what cataract surgery actually does
A cataract is a clouding of your eye’s natural lens. Surgery doesn’t “clean” the lens; it removes it and replaces it with a clear artificial lens (an intraocular lens or IOL). The IOL sits in the same position your lens used to occupy, inside a thin, transparent “bag” called the capsular bag. Getting that cloudy lens out while preserving the bag is the core goal common to all modern techniques.
Why keep the capsular bag? Because it’s the ideal place to seat the new lens so it remains stable and centred for sharp, predictable vision. Much of the art of cataract surgery is making a neat opening in the bag (a capsulotomy), removing the lens material safely, and then positioning the IOL just right.
The three main approaches—at a glance
Before we dive into the details, here’s the simple overview.
- Phacoemulsification: The most common method worldwide. A micro-incision is made in the cornea; ultrasound energy breaks the cataract into tiny fragments that are gently aspirated. It’s quick, efficient, and suits the vast majority of patients.
- Femtosecond laser-assisted cataract surgery (FLACS): A computer-guided laser performs some key steps—creating the corneal incisions, the capsulotomy, and softening the lens—before the surgeon completes the lens removal and IOL implantation. It adds precision and can help in certain situations.
- Extracapsular cataract extraction (ECCE): A larger incision technique where the lens is removed in one piece (or in large sections) without ultrasonic fragmentation. It’s used when the cataract is very advanced or when other eye issues make phaco less safe.
Each approach ends with the same destination: a clear, stable IOL placed in your eye. The journey differs depending on your cataract’s characteristics, your eye’s anatomy, your general health, and the surgeon’s judgement and equipment.
Phacoemulsification: today’s workhorse
How phaco works, step by step
- Anaesthesia and preparation
You’ll usually have numbing drops, sometimes a small anaesthetic injection beside the eye for extra comfort and steadiness. Your eyelids are gently kept open with a small device called a speculum. The skin around the eye is cleaned; a sterile drape is placed. - Micro-incisions
The surgeon makes one main self-sealing incision (often around 2–2.8 mm) at the edge of the cornea and one or two tiny side-ports for instruments. Because these incisions are so small, stitches are rarely needed. - Capsulotomy
A neat circular opening is made in the clear capsule that encases your lens. This has to be smooth and well-centred so the IOL can sit securely afterwards. - Hydrodissection and fragmentation
A small amount of fluid is injected to separate the cataract from the capsule. The phaco probe then uses ultrasonic energy to break the lens into fragments, which are simultaneously suctioned away. - Cortical clean-up
The softer outer layers of the lens (the “cortex”) are removed, leaving an empty, pristine capsular bag. - IOL implantation
A folded IOL is injected through the tiny incision and allowed to unfold inside the bag. The surgeon checks the positioning, rinses the eye, and confirms the incisions are watertight.
When phaco is the best fit
Phaco suits most people. It’s efficient, uses tiny incisions, and has a predictable recovery. It’s particularly good for mild to moderately dense cataracts—though in experienced hands it also copes well with quite firm lenses. If you have a stable cornea, an adequate pupil, and reasonably healthy zonules (the fine fibres that suspend the lens), phaco is almost always the default choice.
Benefits you’ll notice
- Small incision, usually no stitches
- Fast visual recovery for most patients
- Works with the full range of IOL types (monofocal, toric, EDOF, multifocal)
- Widely available, with well-established safety
Potential limitations
- Very dense, rock-hard cataracts can require more ultrasound energy, which the surgeon balances carefully to protect the cornea.
- If zonules are weak (due to trauma, pseudoexfoliation, or other causes), the bag may need support devices (e.g., capsular tension rings) or a different strategy.
What the day feels like
From a patient’s perspective, phaco is calm and quick. You’ll see bright light and occasional shimmering shapes; you shouldn’t feel pain, just pressure or gentle movement. Many people notice improved clarity within hours to days, with fine-tuning as the cornea settles and the pupil returns to normal.
Femtosecond laser-assisted cataract surgery (FLACS): adding computer-guided precision
What the laser does (and doesn’t do)
A femtosecond laser is used at the start of the procedure to perform some “architectural” tasks with extremely high precision:
- It can create the corneal entry incisions.
- It can make the capsulotomy (the circular opening in the capsule) to a pre-planned size and centration.
- It can pre-segment and soften the lens into patterns (like pie sections), reducing the amount of ultrasound needed.
After this laser step—done with you lying under the laser’s docking interface—the rest of the operation continues in the usual sterile theatre with the surgeon removing the lens material and implanting the IOL.
Who might benefit most from FLACS
- Eyes where an exceptionally accurate, centred, and consistently sized capsulotomy is helpful—for example, when implanting premium IOLs that are sensitive to position (e.g., some multifocals or EDOF lenses).
- Very dense cataracts, where laser pre-softening may reduce ultrasound energy.
- Cases where small degrees of corneal astigmatism can be treated with precise, laser-created arcuate incisions.
- Situations where the surgeon wants reproducible precision for teaching, research, or specific anatomical challenges.
Strengths to consider
- High consistency in incision architecture and capsulotomy size/position.
- Potentially gentler on the cornea in dense cataracts due to less ultrasound energy.
- Helpful when targeting exacting refractive outcomes with premium lenses.
Practical trade-offs
- FLACS adds equipment, planning, and steps, which can increase cost.
- Docking the eye to the laser requires cooperation and steady positioning.
- Not all centres have FLACS; not all surgeons consider it necessary for routine cases.
Patient experience on the day
You’ll usually have two stages: the laser room and the operating theatre. The laser part is painless but you’ll feel gentle pressure while the eye is docked; you’ll see patterns of light. The theatre phase then feels similar to standard phaco. Recovery is comparable, with the potential for very precise outcomes when everything else (tear film, cornea, macula) is healthy.
Extracapsular cataract extraction (ECCE): the large-incision, heavy-lifting option
What ECCE involves
ECCE is a more traditional approach designed for very advanced or complicated cataracts. The surgeon makes a larger incision—often 8–12 mm—on the sclera (the white of the eye) or cornea, opens the capsule, and delivers the lens nucleus in one piece (or large sections) using specialised techniques. The softer lens cortex is then cleaned, and an IOL is implanted—often a rigid lens, though foldable options are sometimes used depending on incision size. The wound is closed with stitches.
There’s also a related technique called small-incision cataract surgery (SICS), which uses a self-sealing tunnel and can remove dense lenses with a slightly smaller wound than classic ECCE. Both belong to the extracapsular family: the nucleus exits the eye largely intact rather than being emulsified in situ.
When ECCE is the right call
- The cataract is extremely dense or “mature”, making phaco inefficient or risky.
- The zonules are compromised (weak lens supports), increasing the risk of bag instability during phaco.
- There’s limited access to phaco equipment or the cornea is at higher risk from ultrasound energy.
- Certain complex eyes—after trauma, or with narrow pupils that cannot be safely expanded—may be better served by an extracapsular plan.
What ECCE does well
- Safely removes very hard lenses with less energy inside the eye.
- Gives the surgeon more mechanical control when the capsular bag or zonules are fragile.
- Remains an essential option in complex cases and in settings without phaco technology.
What to weigh up
- The larger incision generally means sutures and a slower recovery.
- There may be more early astigmatism from wound architecture, which can blur vision until stitches are removed or settle.
- Not always a candidate for some premium IOLs depending on incision size and lens design.
How ECCE feels as a patient
The operation is still comfortable with local anaesthesia, but you might be aware of more pressure or movement as the lens is expressed. The eye can feel “tighter” afterwards because of sutures. Vision improves steadily, but it can take longer to reach its best compared to micro-incision techniques.
Choosing between phaco, FLACS, and ECCE: what really drives the decision
You don’t need to become an eye surgeon to make a good choice; you just need a framework. Here are the questions that usually drive the plan:
- How dense and advanced is the cataract?
Mild to moderate density: phaco or FLACS. Very dense or “white/brunescent” cataracts: FLACS (for softening) or ECCE/SICS depending on the surgeon’s view of safety. - How healthy and stable are the cornea, capsule, and zonules?
Normal anatomy: phaco or FLACS. Significant zonular weakness: extracapsular strategies may be safer, sometimes combined with capsular support rings or alternative IOL fixation. - What refractive outcome are you aiming for, and which IOL is planned?
Targeting precise optics—especially with premium lenses—may favour FLACS for its consistent capsulotomy and possible astigmatism control. Monofocal targets without astigmatism may suit standard phaco perfectly. - What technology and expertise are available locally?
Not every centre offers FLACS; not every complex eye needs it. Conversely, a mature cataract in a setting without phaco is often best served by ECCE in expert hands. - What are your personal preferences?
Some people value the highest degree of precision and are willing to pay more for laser assistance; others prefer the simplest approach with the quickest recovery; in complex eyes, safety trumps everything.
What to expect before, during, and after—regardless of method
Before surgery
You’ll have measurements to calculate IOL power (biometry), a check of the cornea and retina, and a discussion about lens options. If you have dry eye, blepharitis, or eyelid issues, your team may treat these first to improve accuracy and recovery. You’ll receive instructions about drops to start before or after surgery and what to bring on the day.
On the day
Arrive with enough time to settle. You’ll change into a gown or cover, lie on a comfortable table, and have drops to dilate the pupil. The operation itself is usually 10–20 minutes for phaco or FLACS theatre time (with a short laser stage for FLACS) and longer for ECCE. You’ll be awake but relaxed; you can talk to the team if you need reassurance.
Immediately after
Vision is often bright but a bit misty the first hours. A protective shield may be placed over the eye. You’ll go home the same day with instructions and a drop regimen to reduce inflammation and prevent infection.
The first week
Most people notice meaningful improvement within a day or two after phaco or FLACS, with steadier gains over the week. ECCE recovers more gradually due to sutures and wound healing. You’ll avoid eye rubbing and follow guidance on showering, exercise, and sleeping posture.
The following weeks
Follow-up checks ensure the IOL is centred and the eye is healing well. Temporary glasses can help if the lens choice leaves you slightly short- or long-sighted as planned; permanent glasses (if needed) are usually prescribed after stabilisation.
Intraocular lenses (IOLs)—the part you live with
Whichever surgical route you take, the IOL is your long-term companion. The main categories are:
- Monofocal: The simplest and most widely used. Sharp focus at one distance (often far), with glasses for other distances.
- Toric: Corrects corneal astigmatism; available as monofocal or some premium designs.
- Extended depth of focus (EDOF): A broader range of clear vision with fewer halos than multifocals for many people, but reading glasses may still be needed for very fine print.
- Multifocal/trifocal: Designed for clear vision at multiple distances, trading a higher chance of halos or night-time glare for more spectacle independence.
- Monovision or blended vision: One eye set slightly for near, the other for distance. Powerful for some, intolerable for others; a contact lens trial beforehand is wise.
The right IOL depends on your lifestyle, your tolerance for visual phenomena (like halos), any occupational needs (night driving, professional pilots, etc.), and your eye’s health (e.g., macular or corneal conditions can reduce suitability for premium lenses). Your surgeon’s measurements and advice are invaluable here.
Safety, risks, and realistic outcomes
Cataract surgery is one of the safest and most successful operations in modern medicine, but no surgery is risk-free. The main risks discussed at consent typically include infection (endophthalmitis, rare), bleeding, inflammation, swelling at the macula, pressure changes, problems with the cornea, and tears in the capsule that can change the plan on the day. Longer term, some people develop posterior capsule opacification (PCO)—a harmless “film” behind the IOL—which is treated quickly with a one-off clinic laser (YAG capsulotomy).
Outcomes are excellent for most patients. Still, perfection isn’t guaranteed: a tiny proportion will need glasses for crispness, a top-up procedure (e.g., fine laser refractive enhancement), or, very rarely, an IOL exchange if the lens isn’t tolerated. Setting the right expectations—and choosing the approach and IOL that match your eyes and life—makes all the difference.
Recovery timelines compared
- Phaco
Back to light daily tasks within 24–48 hours for many; sharper focus builds over the first week. - FLACS
Similar to phaco, with the potential for very precise optical outcomes in well-selected cases. - ECCE
A more measured recovery due to sutures and a larger incision; still very effective, just slower to the finish line.
Remember: your individual timeline depends on pre-existing eye conditions (like dry eye or retinal disease), the density of your cataract, and how your cornea responds. It’s normal for two eyes to recover at slightly different speeds.
Cost and access—what typically changes between methods
Costs vary by region and provider. As a rule of thumb, FLACS may be priced higher than standard phaco due to the laser technology and extra steps. ECCE can be part of standard care in hospitals because it uses fewer consumables but requires more theatre time and follow-up for sutures. Insurance or national health systems often fund medically indicated cataract surgery with monofocal lenses; premium IOLs and FLACS may attract top-up fees privately. If cost matters to you, ask for a transparent breakdown of what’s included (surgeon’s fee, facility, lens type, post-op care, enhancement cover).
How to prepare well—regardless of the technique chosen
- Treat the surface: optimising dry eye or blepharitis beforehand improves biometry accuracy and comfort.
- Share your medications: blood thinners, alpha-blockers, or steroid use can change surgical planning.
- Bring your priorities: whether it’s reading music, driving at night, or seeing a golf ball clearly, your lifestyle targets inform IOL choice.
- Arrange support: a friend or family member for the day of surgery is helpful.
- Follow the drops: consistent anti-inflammatory and antibiotic drops reduce complications and speed comfort.
Putting it together: which of the three is “best”?
There isn’t a universal winner—there’s a best match for you.
- If your cataract is typical and you want a fast recovery with tried-and-tested safety, phaco is the dependable choice.
- If precision is paramount (for instance, with certain premium IOLs, mild astigmatism correction, or dense lenses where energy reduction helps), FLACS may add value.
- If your lens is extremely dense or your eye’s support structures are fragile, ECCE or SICS can be the safest way to reach the same destination: a clear, stable IOL and better vision.
A good consultation will walk you through why your surgeon leans one way or another, show you diagrams or scans, and invite your questions. The aim is shared decision-making, not a mystery hand-off.
FAQs: 10 common questions answered
1) Will I be awake during cataract surgery?
Yes, almost everyone is awake during cataract surgery, but your eye is fully numbed with drops or a small injection so you won’t feel pain. You’ll be aware of light and gentle movement, but not of sharp instruments or detail. The team will talk you through the process, and if you feel anxious, some centres can offer a light sedative to help you relax.
2) Does FLACS guarantee a better result than standard phaco?
Not necessarily. While femtosecond laser-assisted cataract surgery offers more precise incisions and a very consistent opening in the capsule, overall vision quality depends on multiple factors like the health of your cornea and retina, the choice of IOL, and how well your eye heals. In straightforward cases, results from FLACS and phaco are often very similar, though FLACS can provide advantages in selected patients.
3) Why would a surgeon choose ECCE if it’s considered older?
Extracapsular cataract extraction may be older, but it remains an important option when cataracts are extremely dense or when the delicate fibres that hold the lens in place are weak. In these situations, using ultrasound in a small incision can be risky, so ECCE offers a safer way to remove the cataract in one piece. It’s not about “old versus new” but about choosing the safest method for your eye.
4) How soon can I drive after cataract surgery?
Driving depends on how quickly your vision clears and whether it meets the legal standard. Many people can drive within a few days after phaco or FLACS because the small incision heals quickly, but after ECCE recovery is often slower due to stitches and wound healing. Your surgeon will check your vision at follow-up and let you know when it’s safe to get back on the road.
5) Will I still need glasses after surgery?
That depends on the type of IOL you choose and your visual goals. With a standard monofocal lens, you’ll usually see well at distance but will still need glasses for reading or close work. Toric lenses can reduce or correct astigmatism, while multifocal and extended depth of focus lenses aim to give you good vision at several distances with less reliance on glasses. Your surgeon will guide you on the best option for your lifestyle.
6) Is cataract surgery painful?
No, pain during cataract surgery is very uncommon. You might feel some pressure or a cool sensation when fluid is used to wash the eye, but sharp pain is not expected. After the operation, it’s normal to have mild scratchiness, light sensitivity, or watering for a day or two, all of which settle with drops. Most patients are surprised at how comfortable the whole experience is.
7) What complications should I know about?
The vast majority of cataract operations are successful, but every surgery carries some risks. The most important include infection, bleeding, swelling at the back of the eye, and tears in the capsule. Long-term, a cloudy film called posterior capsule opacification (PCO) can develop behind the lens implant, but this is quickly treated with a short outpatient laser procedure. Your surgeon will explain these risks so you know what to look out for.
8) Can premium lenses be used with any of the three techniques?
In most cases, yes. Premium lenses such as toric, multifocal, and EDOF IOLs can be implanted with phaco or FLACS, and they can also be used in ECCE if the incision is suitable. However, some surgeons prefer FLACS for premium IOLs because the laser-created capsule opening can provide extra stability, which helps the lens perform optimally. Suitability always depends on your eye’s anatomy and health.
9) How long does recovery usually take?
Most people notice clearer vision within a day or two after phaco or FLACS, and vision usually stabilises within a couple of weeks. With ECCE, because the incision is larger and stitches are needed, recovery can take longer, sometimes several weeks before vision feels settled. Whichever method is used, the final outcome also depends on how healthy the rest of the eye is, particularly the cornea and retina.
10) What if I have other eye conditions like glaucoma or macular degeneration?
Cataract surgery can still be worthwhile, but expectations need to be realistic. Removing the cataract clears the cloudiness, but if you have glaucoma, macular degeneration, or corneal problems, these conditions may still limit your best possible vision. Your surgeon will assess these carefully and explain what improvement you can reasonably expect so you’re not disappointed after surgery.
Final thoughts
Cataract surgery is a journey with a shared destination—clearer vision—but there are a few roads that lead there. Phacoemulsification is the trusted, everyday path; femtosecond laser-assisted surgery adds computer-guided precision for selected goals; extracapsular extraction remains the reliable heavy-duty route when cataracts are very advanced or the eye’s support structures are fragile. The right choice for you balances safety, your eye’s anatomy, the density of the cataract, your visual priorities, and the technology and expertise available.
Go into your consultation armed with the essentials: ask which method is planned and why, what IOL options match your lifestyle, how recovery is likely to feel, and what the team will do to optimise the surface of your eye before and after. If you’re looking for expert care and advice, the team at London Cataract Centre can guide you through your options and help you choose the safest, most effective route to clearer vision.
References
- de Silva, S.R., Riaz, Y. & Evans, J.R., 2014. Phacoemulsification with posterior chamber intraocular lens versus extracapsular cataract extraction (ECCE) with posterior chamber intraocular lens for age-related cataract. Cochrane Database of Systematic Reviews, Issue 1, Art. No.: CD008812. Available at: https://researchonline.lshtm.ac.uk/id/eprint/4086925/1/Phacoemulsification%20with%20posterior_GREEN%20VoR.pdf [Accessed 12 September 2025].
- Li, A., He, Q., Wei, L., Chen, Y., He, S., Zhang, Q. & Yan, Y., 2022. Comparison of visual acuity between phacoemulsification and extracapsular cataract extraction: a systematic review and meta-analysis. Annals of Palliative Medicine, 11(2), pp.551-559. Available at: https://apm.amegroups.org/article/view/89411/html [Accessed 12 September 2025].
- Seward, H.C., Dalton, R. & Davis, A., 1993. Phacoemulsification during the learning curve: risk/benefit analysis. Eye, 7, pp.164-168. Available at: https://www.nature.com/articles/eye199335.pdf [Accessed 12 September 2025].
- Foster, G.J.L., Allen, Q.B., Ayres, B.D., Devgan, U., Hoffman, R.S., Khandelwal, S.S., Snyder, M.E. & Vasavada, A.R., 2018. Phacoemulsification of the rock-hard dense nuclear cataract: options and recommendations. Journal of Cataract & Refractive Surgery, 44(8), pp.905-916. Available at: https://ascrs.org/-/media/files/clinical-committee-reports/phacoemulsification-of-the-rock-hard-dense-nuclear-cataract.pdf [Accessed 12 September 2025].
- Quinlan, M., 1997. Phacoemulsification versus extracapsular cataract extraction. Journal of Cataract & Refractive Surgery. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC1722027/ [Accessed 12 September 2025].