Comparison of Low-Energy FLACS and Conventional Cataract Surgery: Meta-Analysis and Systematic Review
Yeh CY, Fang HS, Ou YC, Cheng CK, Wu TE1
Industry support: None
ABSTRACT SUMMARY
This meta-analysis compared the safety and effectiveness of low-energy femtosecond laser–assisted cataract surgery (FLACS) using the Femto LDV Z8 platform (Ziemer Ophthalmic Systems) versus conventional phaco cataract surgery (CPCS). Eleven studies were included analyzing 1,680 eyes (637 in the FLACS group and 1,043 in the CPCS group).
STUDY IN BRIEF
A meta-analysis compared the safety and efficacy of low-energy femtosecond laser–assisted cataract surgery (FLACS) using the Femto LDV Z8 platform (Ziemer Ophthalmic Systems) versus conventional phaco cataract surgery (CPCS). Low-energy FLACS was associated with a shorter effective phaco time, less endothelial cell loss at 1, 3, and 6 months, and a lower overall use of balanced salt solution during surgery. No significant differences in cumulative dissipated energy, patients’ corrected distance visual acuity, changes to central corneal thickness, or aqueous cytokine levels (reflecting surgery-associated inflammatory response) were found between groups.
WHY IT MATTERS
This research appears to be the first comparison of low-energy FLACS and CPCS. The meta-analysis highlights the potential advantages of low-energy femtosecond lasers in reducing corneal endothelial damage and improving intraoperative efficiency. The findings indicate that, compared to CPCS, low-energy FLACS enhanced surgical safety without compromising long-term visual outcomes.
Significantly fewer (P < .001) reductions in endothelial cell counts were found at 6 months after low-energy FLACS compared to CPCS. The effective phaco time was also shorter with low-energy FLACS, and less balanced salt solution was used. No differences were found in cumulative dissipated energy, patients’ corrected distance visual acuity, changes in central corneal thickness, or aqueous cytokine levels (reflecting a surgery-associated inflammatory response) between groups.
DISCUSSION
FLACS automates three critical steps of cataract surgery: corneal incisions, the anterior capsulotomy, and nuclear fragmentation. Although FLACS is recognized for its precision, its clinical benefits compared to CPCS remain a subject of debate.
To our knowledge, the meta-analysis by Yeh et al is the first comparison of low-energy FLACS and CPCS. We chose to discuss the research not out of favoritism for a particular femtosecond laser platform but because the use of a single device for all the FLACS procedures reduced potential variability.
The findings by Yeh et al suggest that, compared to CPCS, low-energy FLACS enhances surgical safety without compromising long-term visual outcomes.
Comparing the Efficacy and Safety Between Femtosecond Laser-Assisted Cataract Surgery and Conventional Phacoemulsification Cataract Surgery: Systematic Review and Meta-analysis
Song X, Li L, Zhang X, Ma J2
Industry support: None
ABSTRACT SUMMARY
This systematic review and meta-analysis examined 41 randomized controlled trials involving 9,310 eyes to compare the safety and efficacy of FLACS and CPCS.
STUDY IN BRIEF
A systematic review and meta-analysis of 41 randomized controlled trials compared the safety and efficacy of femtosecond laser–assisted cataract surgery (FLACS) and conventional phaco cataract surgery (CPCS). Regardless of the laser platform, FLACS provided superior visual outcomes in the early postoperative period and during long-term follow-up, a more precise capsulotomy, and a better effective lens position. No significant difference in midterm visual outcomes was observed. The safety profiles of FLACS and CPCS were comparable.
WHY IT MATTERS
This large meta-analysis presents compelling evidence of the advantages FLACS offers compared to CPCS.
Main outcome measures included patients’ uncorrected and corrected distance visual acuity, capsulotomy parameters, effective lens position, and intra- and postoperative complications. Secondary outcomes included manifest refraction spherical equivalent, mean absolute error, mean phaco time and energy, cumulative dissipated energy, effective phaco time, balanced salt solution usage, central corneal thickness, and postoperative endothelial cell loss.
Both FLACS and CPCS were found to be safe and effective. Notably, the FLACS group’s visual outcomes were superior in the early postoperative period and during long-term follow-up, the capsulotomy was more accurate, and the effective lens position was better. No significant difference in visual outcomes was found at midterm follow-up.
DISCUSSION
This large meta-analysis found that FLACS offered some advantages over CPCS and the procedures had comparable safety. FLACS, however, demands a higher initial capital investment than CPCS and may be less accessible in areas with limited health care infrastructure and resources. Additionally, experienced FLACS users frequently state that comfortable expertise requires a learning curve estimated at several hundred to 1,000 cases based on their broad clinical experience rather than these two meta-analyses.1,2 This mirrors the adoption trajectory of phacoemulsification in the 1980s. Including FLACS in training programs and simulation-based learning could facilitate surgeon adoption and technical proficiency.
Not all patients benefit equally from FLACS. Further research is required to determine when the procedure offers the most advantages. Customizing laser parameters based on specific case expectations could optimize outcomes. Moreover, additional randomized controlled trials are warranted to compare the long-term cost-effectiveness of FLACS using different platforms to that of CPCS for specific case types. Finally, emerging AI-assisted surgical planning tools may enhance the precision of FLACS by optimizing incision placement and energy settings.
1. Comparison of low-energy FLACS and conventional cataract surgery: meta-analysis and systematic review. J Cataract Refract Surg. 2024;50(10):1074-1082.
2. Song X, Li L, Zhang X, Ma J. Comparing the efficacy and safety between femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery: systematic review and meta-analysis. Can J Ophthalmol. 2025;60(1):e1-e10.
