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59 EW RESIDENTS January 2019 the two groups, contrary to several prior studies that have demonstrated less energy with FLACS. 7–9 Addition- ally, while the effect of the learning curve was addressed by ensuring sur- geons had completed at least 30 pri- or femtosecond cases, the learning curve still may have been a factor in the complication rate; it has been shown previously that complica- tions are more likely to occur in the first 100 to 200 cases. 10,11 (3) Finally, while the study is powered appropri- ately to detect a 0.1 logMAR VA, it is unlikely that it was large enough to effectively detect differences in relatively rare complications, such as capsular tears or suprachoroidal hemorrhages. It should be emphasized that la- ser systems are expensive. The same group previously estimated that FLACS adds approximately $220 to each cataract procedure. 12 Therefore, it is important to determine whether or not the increased cost associated with this procedure is mitigated by a reduction in complication rates and better patient outcomes. Studies such as this are important to further understand the role of FLACS in modern cataract surgery and ultimately help ophthalmolo- gists choose a safe and cost-effective surgery for their patients. EW References 1. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol. 2006;90:262–7. 2. Lawless M, Hodge C. Femtosecond laser cataract surgery: an experience from Austra- lia. Asia Pac J Ophthalmol. 2012;1:5–10. 3. Kranitz K, et al. Femtosecond laser cap- sulotomy and manual continuous curvilinear capsulorrhexis parameters and their effects on intraocular lens centration. J Refract Surg. 2011;27:558–63. 4. Kranitz K, et al. Intraocular lens tilt and de- centration measured by Scheimpflug camera following manual or femtosecond laser-creat- ed continuous circular capsulotomy. J Refract Surg. 2012;28:259–63. 5. Chen X, et al. Comparing the curative effects between femtosecond laser-assisted cataract surgery and conventional phacoemul- sification surgery: a meta-analysis. PLoS One. 2016;11:e0152088. thickness (p=0.55), mean change in Cat-PROM5 score (p=1), and mean change in EQ-5D-3L index score (p=1). Total rates of intraoperative or postoperative complications did not show a difference. Mean change in EQ-5D visual analogue scale was unchanged in the FLACS group but increased in the CPS group (p=0.02). Posterior capsular tear occurred at a significantly higher rate in the CPS group (p=0.03). The main strength of this study is that it is the largest randomized interventional case-controlled trial designed to date comparing FLACS and CPS. The study's follow-up of 4 weeks appears adequate for the pri- mary outcome measure (uncorrected distance VA) given the fact that the majority of postoperative edema and inflammation tends to be resolved by this time postoperatively. An- other strength was the fact that VA and any ancillary tests performed were conducted by an optometrist or technician masked to the partici- pant's treatment arm, which reduces detection bias. Additionally, this was the first large-scale randomized controlled trial to evaluate the rate of cystoid macular edema between FLACS and CPS, which was similar between the two arms. The study has some limitations. (1) Lack of data regarding immediate postoperative evaluation: FLACS might have been superior in the ear- ly phase due to reduced ultrasound energy and reduced corneal edema, which translates into faster visual recovery. Additionally, cataract and glaucoma frequently coexist in the same patient and differences in early intraocular pressure (IOP) spikes may have been missed, which has an important implication in glauco- ma patients' care. (2) Surgeries were performed by only three surgeons at a single institution; these sur- geons' experience levels, patient population, and surgical preferences may not be representative of other practices. For example, their pref- erence for segmentation pattern instead of grid pattern may have led to their finding of no difference in phacoemulsification energy between 6. Day AC, et al. Laser-assisted cataract sur- gery versus standard ultrasound phacoemulsi- fication cataract surgery. Cochrane Database Syst Rev. 2016;7:CD010735. 7. Conrad-Hengerer I, et al. Effect of fem- tosecond laser fragmentation on effective phacoemulsification time in cataract surgery. J Refract Surg. 2012;28:879–83. 8. Brunin G, et al. Outcomes of femtosecond laser-assisted cataract surgery performed by surgeons-in-training. Graefes Arch Clin Exp Ophthalmol. 2017;255:805–809. 9. Yesilirmak N, et al. Differences in energy expenditure for conventional and femtosec- ond-assisted cataract surgery using 2 differ- ent phacoemulsification systems. J Cataract Refract Surg. 2017;43:16–21. 10. Bali SJ, et al. Early experience with the femtosecond laser for cataract surgery. Oph- thalmology. 2012;119:891–9. 11. Roberts TV, et al. Surgical outcomes and safety of femtosecond laser cataract surgery: a prospective study of 1500 consecutive cases. Ophthalmology. 2013;120:227–33. 12. Roberts HW, et al. Financial modelling of femtosecond laser-assisted cataract surgery within the National Health Service using a 'hub and spoke' model for the delivery of high-volume cataract surgery. BMJ Open. 2017;7:e013616. Contact information Taravati: taravati@uw.edu comparing femtosecond laser assisted phacoemulsification surgery" A randomized controlled trial comparing femtosecond laser assisted cataract surgery vs. conventional phacoemulsification surgery H.W. Roberts, MSc, V.K. Wagh, MD, D.L. Sullivan, MSc, P. Hidzheva, MCOp- tom, D.I. Detesan, B.S. Heemraz, J.M. Sparrow, DPhil, D.P.S. O'Brart, MD J Cataract Refract Surg. 2018;45(1):11–20. Purpose: To compare the clinical results of conventional phacoemulsification surgery (CPS) to femtosecond laser (FL) assisted cataract surgery (FLACS). Setting: Guy's & St Thomas' NHS Foundation Trust, London, U.K. Design: Single-center prospective randomized interventional case- controlled trial Methods: 400 eyes of 400 patients undergoing cataract surgery were randomized to receive either CPS or FLACS. FLACS was performed with a LenSx (Alcon, Fort Worth, Texas), and all operations were performed with an Infiniti machine (Alcon). Visual acuity (VA), refraction, central corneal thickness (CCT), central foveal thickness (CFT), endothelial cell loss (ECL), and rates of intraoperative and postoperative complications were recorded. Quality of life outcomes were measured with EuroQOL's EQ-5D and patient reported quality of vision with Cat-PROM5. Results: 400 eyes of 400 patients were randomized to receive CPS (n=200) or FLACS (n=200). 3.5% of FLACS patients were not able to complete FL treatment and received CPS. Unaided VA (logMAR) after CPS was 0.15 ± 0.21 and 0.15 ± 0.19 after FLACS (p=1), and pinhole corrected VA was 0.04 ± 0.12 and 0.04 ± 0.12, respectively (p=1). Increase in CCT was 13 μm ± 19 after CPS and 15 μm ± 25 after FLACS (p=0.5). ECC loss was –9.7% ± 13.7 after CPS and –10.2% ± 13.7 after FLACS (p=0.76). Refractive mean spherical equivalent error was –0.14 ± 0.60 D after CPS and –0.12 ± 0.60 D for FLACS (p=0.74). Change in CFT was 9 μm ± 35 after CPS and 6 μm ± 35 after FLACS (p=0.55). Rate of posterior capsular rupture (PCR) was 3% and 0%, respectively (p=0.03). Conclusions: This study confirms, in the majority, the non-significant differences between these two treatment modalities notwithstanding a significant reduction in PCRs in the FLACS group.

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