Eyeworld

EW RESIDENTS 84 December 2016 database patients who underwent standard cataract surgery, the overall study population was likely younger and healthier than the EUREQUO patient database. Some key differ- entiating outcome measures such as shape and centration of the cap- sulorhexis, effective lens position, phacoemulsification energy used, and endothelial cell counts were not tracked. The extent of femtosecond laser use within the case was also not standardized, and thus laser was used to different extents in the various patients. The advent of the femtosecond laser offers a potential improvement on the already successful cataract surgery. In an age with educated pa- tients who desire the latest surgical technology, it is important that oph- thalmologists offer innovative meth- ods that are novel and proven to be of clinical benefit. This study found that postoperative visual outcomes, refractive outcomes, and intraop- erative complications were similar between the different methods of cataract surgery with and without femtosecond laser use. The overall postoperative complication rate was higher in those with femtosecond laser assistance, largely due to minor laser-specific complications, with worse initial postoperative visual acuity due to corneal edema, early PCO, and uveitis. Based on these results, there is no evidence that FLACS is superior in comparison to CPCS. However, both options offer excellent visual outcomes and low complication rates. EW References 1. Grewal DS, et al. Femtosecond laser-as- sisted cataract surgery—current status and future directions. Surv Ophthalmol. 2016;61:103–131. 2. Donaldson KE, et al. Femtosecond laser- assisted cataract surgery. J Cataract Refract Surg. 2013;39:1753–1763. 3. Nagy ZZ, et al. Comparison of intraocular lens decentration parameters after femto- second and manual capsulotomies. J Refract Surg. 2011;27:564–569. 4. Friedman NJ, et al. Femtosecond laser cap- sulotomy. J Cataract Refract Surg. 2011;37: 1189–1198. 5. Qian DW, et al. Femtosecond laser capsulotomy versus manual capsulotomy: a meta-analysis. Int J Ophthalmol. 2016;9:453– 458. 6. Schultz T, et al. Changes in prostaglandin levels in patients undergoing femtosecond laser-assisted cataract surgery. J Refract Surg. 2013;29:742–7. Contact information Kloek: Carolyn_Kloek@meei.harvard.edu and lens fragmentation. By creat- ing a more consistent capsulotomy and reducing phacoemulsification energy requirements, FLACS theo- retically could result in improved refractive outcomes as compared to conventional CPCS. However, the relative safety of FLACS as com- pared with CPCS remains unknown, and doubt exists over universally adopting the procedure. This report is the first well-powered, multi- center study that compares clinically relevant outcomes between FLACS and CPCS. In this registry-based, case-control study, both FLACS and CPCS showed excellent visual acuity outcomes with low rates of com- plications. However, the data failed to show that FLACS was safer or resulted in better visual outcomes as compared with CPCS. Specifically, the study results did not show a clear difference between the two groups in intraoperative or postoperative complications. Despite overall intraoperative complication rates being statistically higher in the FLACS group compared with the CPCS group, they were similar when FLACS-specific complications were taken out of consideration. Howev- er, the FLACS-specific intraoperative complication rate was high at 2%, which included incision-related complications, anterior capsule com- plications, and capsulotomy com- plications. Overall visual outcomes were statistically worse in the FLACS group, although likely not clinically significant since the CPCS group saw on average just one letter better in the postoperative study period. Finally, overall postoperative com- plications were higher in the FLACS group in most of the parameters measured, including corneal edema, early PCO, uveitis, and intraocular pressure spikes. This difference in postoperative complications is likely to be clinically relevant regarding refractive outcomes and patient sat- isfaction. However, given the high percentage of multifocal IOLs in the FLACS group, a comparison was performed between postop complications in FLACS and CPCS using only monofocal IOLs. When evaluating monofocal lenses only, the overall percentage of postop- erative complications between the two groups was not statistically significant. However, there still was a greater percentage of patients undergoing FLACS with postopera- tive corneal edema, early PCO, and uncontrolled IOP that was statisti- cally significant. This data suggests that FLACS may be more pro-in- flammatory, which may be mediated by elevated prostaglandin levels in FLACS cases. 6 Interestingly, cystoid macular edema was not captured by EUREQUO as a separate postopera- tive complication, and therefore, the incidence of this commonly evalu- ated complication related to cataract surgery could not be compared be- tween the two surgical techniques. If FLACS is more pro-inflammatory, there may be a higher percentage of these patients with postoperative macular edema. There was a difference in the type of ocular comorbidities and ocular findings that could increase surgical difficulty between the two groups. There were a greater number of patients with diabetic retinopathy, white cataracts, small pupils, deep set eyes, kyphosis, or inability to position for surgery in the CPCS group. These differences may indicate some level of surgeon preference for eyes with less disease and ease of positioning to qualify for FLACS. Also, the laser has its limita- tions and may not be able to pen- etrate opaque material, may have more capsulotomy complications in the setting of a white cataract, may risk injuring the iris in the setting of a small pupil, or may not be able to dock to a patient due to positioning issues or facial anatomy. The FLACS group had a higher rate of patients with previous corneal refractive sur- gery, which may be related to FLACS surgeons having more corneal refractive surgery patients, who then subsequently need cataract surgery. There are several limitations to this study. The follow-up period was limited to 2 months, although the primary distinguishing complica- tions typically occur early. The study population was obtained retrospec- tively by registry review, and thus the decision for femtosecond laser use was made at the time of surgery based on patient preference and surgeon discretion. The authors attest that younger patients with better preoperative vision were more likely to undergo FLACS. After these patients were matched with similar Review continued from page 82 Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: Case-control study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery Sonia Manning, MD, Peter Barry, FRCS, Ype Henry, MD, Paul Rosen, FRCS, Ulf Stenevi, MD, David Young, PhD, Mats Lundström, MD J Cataract Refract Surg. 2016;42(12). Article in press Purpose: To compare the visual, refractive and adverse outcomes of femtosecond laser-assisted cataract surgery (FLACS) to conventional phacoemulsification cataract surgery (CPCS). Setting: Cataract surgery clinics in 9 European countries and Australia (FLACS) and in 18 European countries and Australia (CPCS). Design: Multicenter case control study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO). Methods: Eyes undergoing FLACS were selectively matched to eyes from the existing EUREQUO CPCS database, for preoperative corrected distance visual acuity (CDVA), age and preoperative risk factors. The two groups were compared for intraoperative and postoperative complications, postoperative CDVA, absolute biometry prediction error (BPE), preoperative and postoperative corneal astigmatism and surgically induced astigmatism (SIA). Follow-up was 7–60 days. Results: A total of 2,814 FLACS cases were matched to 4,987 CPCS cases. The majority were female (57%) with mean age 66 years and baseline logMAR CDVA 0.32 (6/12-1). Posterior capsule complications were not significantly different (FLACS: 0.4 %; CPCS: 0.7%). Postoperative logMAR CDVA differed by one letter (FLACS: 0.05 [6/6- 3]; CPCS: 0.03 [6/6-2]). At follow-up, FLACS versus CPCS compared as follows: worse postoperative CDVA (by 5 letters or more): 1% versus 0.4%; % CDVA 0.3 (6/12) or better: 96.3% versus 97.1%; absolute BPE: 0.43 D versus 0.40 D; % within ±0.5 D of target: 72% versus 74.3%; postoperative complications: 3.4% versus 2.3%. Conclusions: FLACS did not have superior visual or refractive outcomes compared to CPCS. Intraoperative complications were similar and low in both groups. Postoperative complications were lower in CPCS.

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