A new study published in Scientific Reports compared the efficacy and safety of femtosecond laser-assisted cataract surgery (FLACS) to conventional phacoemulsification cataract surgery (phaco).
Give me some background.
Studies have highlighted the benefits of FLACS, including:
- Capsulotomy circularity
- Reduced phaco time
- Decreased corneal endothelial cell loss (ECL)
Though: FLACS also poses unique complications such as suction issues and nonperforated laser corneal incisions, which may require manual intervention.
What have prior studies said about FLACS vs phaco?
Previous analyses have not definitively favored either technique in terms of efficacy or safety outcomes; though some have reported conflicting results in terms of rates of posterior capsular tears in both procedures.
- Consequently: There is ongoing debate regarding the optimal surgical technique.
Let’s get into the study.
In this meta-analysis of randomized controlled trials (RCTs), investigators searched PubMed, Cochrane CENTRAL, and ClinicalTrials.gov databases from 2011 up to January 2023.
In total, the research team included 46 RCTs (8,871 eyes: 4,479 FLACS and 4,392 phaco).
- Who made up the study cohort: The majority of studies came from Europe (58%) and the mean age of participants ranged from 52.8-79.1 years.
Findings?
FLACS resulted in significantly better corrected distance visual acuity (CDVA) 1 week postoperatively (P = 0.0011).
Additionally: FLACS demonstrated preliminary superiority to phaco in terms of effective phaco time (EPT) and cumulative dissipated energy (CDE).
However: There were no significant differences across other factors, such as:
- CDVA beyond 1 week (P = 0.161, 0.429, 0.403)
- Uncorrected distance VA (P = 0.171, 0.136, 0.322, 0.149)
- Spherical equivalence
- Surgically induced astigmatism
How did they compare in terms of safety?
No notable differences were observed in overall complications (P = 0.999), which included:
- Macular or corneal edema within 3 months
- Elevated intraocular pressure (IOP) within 24 hours
- Posterior capsular opacification within 12 months
What about patient-reported outcomes?
The patient-reported health, visual, and daily-activity outcomes were similar between FLACS and phaco.
In terms of extended-term and patient-centered outcomes, the research team identified no substantial disparities between FLACS and phaco.
- Further: Subgroup analyses demonstrated consistent efficacy and safety across diverse laser platforms.
Note: FLACS exhibited no clear cost-effectiveness advantage over phaco, largely due to extended operative times and higher instrument costs.
Expert opinion?
While the study authors emphasized that FLACS is not a cost-effective alternative to phaco for routine cases, they did note that “it may offer benefits in specific challenging scenarios not fully captured in this study.
Examples of this include in “very dense cataracts requiring less ultrasound energy or in eyes with corneal dysfunction where minimizing ECL is critical,” they explained.
Any notable limitations?
These included:
- Though preoperative measurements, intraocular lens (IOL) power calculations, and IOL types influenced postoperative VA, but many studies didn’t specify the type of IOL used
- Potential bias was introduced due to varied follow-up times, complication assessment times, diverse patient-reported outcome questionnaires
- There was limited reporting on cataract density and surgical settings
- Heterogeneity arose from regional differences, protocols, laser steps, surgical expertise, and reporting discrepancies
- None of the included RCTs specified pregnancy in their eligibility criteria, so the findings should not be extrapolated to pregnant patients
Tie it all together for me.
These findings demonstrate that both FLACS and phaco yielded comparable extended-term results encompassing visual outcomes, surgical efficacy, complications, and patient-reported outcomes.