Issue: January 2016
January 19, 2016
3 min read

ESCRS FLACS study update: More postop complications reported with femto than phaco

Worse postoperative visual acuity was also seen with femtosecond laser-assisted cataract surgery vs. phacoemulsification.

Issue: January 2016
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Femtosecond laser-assisted cataract surgery may not currently outperform phacoemulsification, according to the updated European Society of Cataract and Refractive Surgeons FLACS study.

Peter Barry, FRCS, presented the preoperative comorbidities and surgical difficulties, as well as the postoperative results of femtosecond vs. phacoemulsification cataract procedures, at the ESCRS annual meeting.

“Yes, femtosecond laser patients have less postoperative astigmatism and less surgery-induced astigmatism,” Barry said. “But femtosecond laser patients have worse postoperative VA, more postoperative complications reducing VA and more patients with a postoperative VA worse than they endured before surgery.”

Study design

A total of 2,814 prospective femtosecond laser-assisted cataract surgery cases from December 2013 to May 2015 were collected from 16 centers in 10 countries in Europe. Controls were selected retrospectively from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO) 2014 database following rigorous matching criteria.

Peter Barry

The criteria included precisely the same visual acuity, the same age within 2 years, and the same “yes/no” scores in response to ocular comorbidity and surgical difficulty.

In the study design, surgeons were self-selected with a learning curve of at least 50 cases performed, while patients were surgeon-selected and consecutive cases had to be submitted.

Preoperative comparison

In terms of preoperative surgical difficulty, 4% of femtosecond patients had previous corneal refractive surgery compared with only 0.1% of phacoemulsification patients. Both groups had a similar number of cases with preoperative white cataract, pseudoexfoliation, previous vitrectomy, corneal opacities and small pupils, Barry said.

There were no significant differences between the groups in terms of preoperative ocular comorbidities such as glaucoma, macular degeneration, diabetic retinopathy and amblyopia.

The overall rate of surgery complications was higher in the femtosecond laser group, but when femtosecond laser-specific complications were excluded, complications were lower in the femtosecond laser group. The risk of torn posterior capsule, vitreous loss and dropped nucleus was the same in both groups.

Postoperative outcomes

Although the study found the femtosecond procedure to result in significantly better outcomes in terms of postoperative and surgically induced astigmatism, postoperative complications outnumbered those of phacoemulsification surgery, leading to a significantly higher percentage of patients with worse visual acuity than before surgery, Barry said.

“Perioperative complications were more frequent with femto, but not when you excluded femto-specific complications such as inability to dock and various capsular problems,” he said.

The overall number of postoperative surgical complications was significantly higher in the femtosecond group, with more cases of corneal edema, early posterior capsule opacification reducing visual acuity and uveitis requiring treatment.

Although the percentage of patients whose vision improved was equal in the two groups, these complications explain why “a striking 3.3% of patients in the femto group lost lines of vision compared to 1.3% in the phaco group,” Barry said.

“If you try to say that is because the femtosecond cataract patients are younger and probably have less cataract and better vision when they start, therefore it is reasonable to expect them to have worse vision afterward, that isn’t true because we specifically matched the patients to have the same visual acuity preoperatively in both groups,” he said.

In regard to postoperative astigmatism, the femtosecond procedure showed advantages. The percent of patients with cylinder of 1.5 D or greater was 18.5% in the phaco group and 9% in the femtosecond laser group.


“This improvement is still maintained if you remove patients receiving toric IOLs, concurrent femto-refractive surgery and previous corneal refractive surgery,” Barry said.

Postoperative surgically induced astigmatism was also significantly lower with femtosecond laser.

Evaluating IOLs

Researchers also evaluated monofocal vs. premium IOLs, in which 55% of femtosecond cases received premium IOLs, whereas more than 99% of phacoemulsification patients received monofocal IOLs, Barry said.

“That is somewhat worrying that the multifocal use seemed to have the lower postoperative visual acuity,” he said.

Barry said he would have liked to conduct a substudy in terms of stratifying the types of IOLs, but the EUREQUO database could not support such results.

“The problem is that in the database the utilization of multifocal toric IOLs is very small and would not be possible despite the fact of having 1.75 million people in the database,” he said. “There would not be enough patients to have so-called premium IOLs.” – by Michela Cimberle and Kristie L. Kahl

Disclosure: Barry reports no relevant financial disclosures.