Eyeworld

EW RESIDENTS 70 December 2017 visual acuity. Group 1 had acuity logMAR 0.0 or better and Group 5 had acuity logMAR 0.6 or worse, with other groups having acuities in between. Relative to patients with good baseline visual acuity, patients with poor baseline visual acuity had a number of distinguishing charac- teristics. Preoperatively, they had more ocular comorbidities. Intra- operatively, they had more surgical complications and were more likely to receive monofocal lenses. Postop- eratively, their refractive outcome was slightly worse than for patients with good baseline visual acuity, but they enjoyed a larger magnitude of visual improvement and had an equivalent rate of complications. Overall, this paper supports prior reports demonstrating compa- rable refractive outcomes of FLACS and manual phacoemulsification. It adds to the existing knowledge base by examining how FLACS efficacy varies with baseline visual acuity of operative eyes. This article highlights in mul- tiple ways the important issue of patient selection in FLACS. This is poignantly illustrated by the au- thors' finding that patients with the best preoperative visual acuity are at the highest risk of having worse visual acuity after surgery (5.9%), a finding also demonstrated in other cataract surgery cohorts. 5 The deci- sion to proceed with cataract surgery should thus be weighed carefully in patients with very good preoperative visual acuity. In these situations, the surgery may be better classified as a refractive lens exchange rather than a cataract extraction, and this should be reflected in the counseling provided to patients on the risks and benefits of surgery. The fact that patients in this study were younger than earlier FLACS studies 6 suggests that the indications for FLACS, and perhaps cataract surgery in general, may indeed be moving toward what the authors describe as a "gray zone between refractive lens exchange and cataract extraction." Of note, nearly 75% of the patients included in this study did not have enough preoperative visual impairment to inhibit reading and driving. The shift to operating on younger pa- tients with better preoperative acuity has been ascribed to, among other things, a diminishing population proportion of advanced cataracts and development of newer technol- ogies including FLACS, which give surgeons a perceived lower risk of complication. 7 Also demonstrating the rele- vance of patient selection in FLACS is the finding of this report that FLACS patients had fewer preop- erative ocular comorbidities than other phacoemulsification cohorts (19.1% vs. 37.5%). 8 The authors speculate that surgeons may have been selective in recruiting patients with few preoperative comorbidi- ties for FLACS due to hesitance to employ new technology in poten- tially risky cases. Interestingly, even with selection of patients with fewer preoperative ocular comorbidities, FLACS had a nontrivial postoper- ative complication rate. This was in spite of restricting inclusion to surgeons with at least 50 previous FLACS cases, which would limit any "learning curve" effect that could further increase the risk of complica- tions. It was also in spite of having an average follow-up time of only 34 days, which would exclude late com- plications such as posterior capsule opacification and late endophthal- mitis. The rate of FLACS postoper- ative complications thus deserves further investigation, as the authors acknowledge. This study further highlights the importance of patient selection in FLACS by reporting characteristics of patients receiving multifocal intra- ocular lenses. Approximately 40% of subjects received multifocal intra- ocular lenses. The most frequent recipients were patients with good preoperative visual acuity, as might be expected given current opinions on indications and contraindica- tions for multifocal intraocular lens placement. 9 While FLACS provides a theoretic benefit for multifocal lens implantation by creation of a cen- tered circular capsulorhexis, there has been no observed difference in postoperative visual acuity com- pared to manual phacoemulsifica- tion. 10 Although this study does not address financial considerations, the lack of clear superiority over manual phacoemulsification warrants fur- ther examination of the benefit-cost ratio of FLACS. EW References 1. He L, et al. Femtosecond laser-assisted cataract surgery. Curr Opin Ophthalmol. 2011;22:43–52. 2. Abell RG, et al. Femtosecond laser-assisted cataract surgery compared with conven- tional cataract surgery. Clin Exp Ophthalmol. 2013;41:455–62. 3. Popovic M, et al. Efficacy and safety of femtosecond laser-assisted cataract surgery compared with manual cataract surgery: a meta-analysis of 14567 eyes. Ophthalmology. 2016;123:2113–26. 4. Ewe SY, et al. A comparative cohort study of visual outcomes in femtosecond laser-as- sisted versus phacoemulsification cataract surgery. Ophthalmology. 2016;123:178–82. 5. Lundström M, et al. Visual outcome of cataract surgery; study from the European Registry of Quality Outcomes for Cataract and Refractive Surgery. J Cataract Refract Surg. 2013;39:673–9. 6. Abell RG, et al. Femtosecond laser-assisted cataract surgery versus standard phacoemul- sification cataract surgery: outcomes and safety in more than 4000 cases at a single center. J Cataract Refract Surg. 2015;41: 47–52. 7. Lundström M, et al. The changing pattern of cataract surgery indications: a 5-year study of 2 cataract surgery databases. Ophthalmology. 2015;122:31–8. 8. Lundström M, et al. 1998 European Cata- ract Outcome Study: report from the European Cataract Outcome Study Group. J Cataract Refract Surg. 2001;27:1176–84. 9. Braga-Mele R, et al. Multifocal intraocular lenses: relative indications and contraindica- tions for implantation. J Cataract Refract Surg. 2014;40:313–22. 10. Lawless M, et al. Outcomes of femtosec- ond laser cataract surgery with a diffractive multifocal intraocular lens. J Refract Surg. 2012;28:859–64. Contact information Goshe: goshej@ccf.org Purgert: purgerr@ccf.org Review continued from page 68 Femtosecond laser-assisted cataract surgeries (FLACS) reported to the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO): baseline characteristics, surgical procedure, and outcomes Mats Lundström, MD, Mor Dickman, MD, Ype Henry, MD, Sonia Manning, MD, Paul Rosen, FRCS, Marie-José Tassignon, MD, David Young, PhD, Ulf Stenevi, MD J Cataract Refract Surg. 2017;43(12). Article in press. Purpose: To describe a large cohort of femtosecond laser-assisted cataract surgeries (FLACS) in terms of baseline characteristics and the related outcomes. Setting: Eighteen cataract surgery clinics in nine European countries and Australia. Design: Prospective multicenter cohort registry study. Methods: Data about consecutive eyes undergoing FLACS in the participating clinics were entered into the European Registry of Quality Outcomes for Cataract and Refractive Surgery (EUREQUO). A specifically trained registry manager in each clinic was responsible for valid reporting to the EUREQUO. Data on demographics, preoperative corrected distance visual acuity (CDVA), risk factors, type of surgery, type of intraocular lens (IOL), visual outcome, refractive outcome, and complications were reported. Results: Complete data were available for 3,379 cases. The mean age was 64.4 (±10.9) years, and 57.8% (95% CI 56.1–59.5) of the patients were female. A surgical complication was reported in 2.9% (95% CI 2.4–3.5) of all cases (2.2% FLACS-related like laser incision: 0.8% and laser capsulotomy: 0.5% and in 0.7% ordinary phacoemulsification- related complications). The mean postoperative CDVA was logMAR 0.04 (±0.15). A biometry prediction error (spherical equivalent) was within ±0.5D in 71.8% (95% CI 70.3–73.3) of all surgeries. Postoperative complications were reported in 3.3% (95% CI 2.7–4.0). Patients with good preoperative CDVA generally had the best visual and refractive outcome; patients with poor preoperative visual acuity had poorer outcomes. Conclusions: The visual and refractive outcomes of FLACS were favorable compared to manual phacoemulsification. The outcome was highly influenced by the preoperative visual acuity, but all preoperative visual acuity groups showed an acceptable outcome.

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