Eyeworld

37 EW RESIDENTS May 2018 2. Conrad-Hengerer I, et al. Corneal endo- thelial cell loss and corneal thickness in conventional compared with femtosecond laser-assisted cataract surgery: three- month follow-up. J Cataract Refract Surg. 2013;39:1307–13. 3. Chen X, et al. Clinical outcomes of femto- second laser-assisted cataract surgery versus conventional phacoemulsification surgery for hard nuclear cataracts. J Cataract Refract Surg. 2017;43:486–491. 4. Gavris M, et al. Fuchs' endothelial corneal dystrophy: Is femtosecond laser-assisted cataract surgery the right approach? Rom J Ophthalmol. 2015;59:159–63. Contact information Tapino: Paul.Tapino@uphs.upenn.edu technological innovation of FLACS, it has been the challenge of clini- cians to define the precise role of this expensive adjunct to cataract surgery. For now, the evidence does not support a benefit of FLACS over conventional phacoemulsification in patients with FECD. We await the report of data from the FEMCAT study, a large French RCT comparing FLACS with phacoemulsification without additional costs to the patient. EW References 1. Abell RG, et al. Toward zero effective phacoemulsification time using femtosec- ond laser pretreatment. Ophthalmology. 2013;120:942–8. gested that FLACS may be useful in patients with FECD given a possible reduction in endothelial cell loss compared to manual surgery, 2,3 how- ever, the authors point out that the only other study of FLACS specifical- ly in patients with FECD is a small series without controls. 4 In summa- ry, the authors conclude that FLACS does not decrease the rate of clini- cally significant corneal decompen- sation and progression to transplan- tation in eyes with mild to moderate FECD. Surprisingly, the FLACS group fared worse in early clinically appar- ent edema and clinically severe ede- ma. However, these differences were mostly limited to the first week. The authors proposed several reasons for these early differences including relative surgeon inexperience with FLACS, greater loss of endothelium from laser-assisted incisions, greater difficulty of cortex removal in FLACS, and increased prostaglandin release with FLACS. This study does, however, have several limitations. First, this is a retrospective cohort study, and therefore susceptible to unrecognized confounding vari- ables. Although this study was not randomized, the authors remark that the better baseline visual acuity and lower rate of preoperative CCT measurements in the FLACS cohort would, if anything, favor the FLACS group. The exclusion of patients with complications related to cata- ract surgery may possibly favor one cohort or exclude data germane to the study question. Additionally, we would like to have known, even if anecdotal, what factors went into the decision between the surgeon and patient to perform FLACS versus conventional phacoemulsification. This is especially useful to know since FLACS in the United States confers an added out of pocket expense to the patient. Despite the corneal decompensation, which was defined as resulting in BCVA worse than 20/50 for at least 3 months or requiring corneal transplantation. Mean duration of follow-up time was 30 months. In this study, 17% of eyes (11 of 64 eyes) in the FLACS group and 10% of eyes (15 of 143 eyes) in the conventional group progressed to clinically significant corneal decom- pensation, however, this difference was not statistically significant. The overall transplantation rates were 8% vs. 9% for the FLACS group and conventional group, respectively, and average time to transplantation (6 ± 5.2 months) was not significant- ly different between both groups. Analysis of preoperative cataract and corneal guttata grades did not reveal a significant difference in decom- pensation rates between treatment groups. This report did show that postoperative edema at 1 month was significantly higher for the FLACS group (47% vs. 30%; p<0.05), but by 3–6 months rates equalized between groups. Incidence of severe corne- al edema defined as BCVA 20/400 or CCT greater than 700 μm was significantly greater for the FLACS group (23% vs. 11%, p<0.05). How- ever, in the majority of cases, edema decreased substantially after the first week. This report showed that there was not a statistically significant difference in postoperative BCVA be- tween the FLACS and conventional groups. More advanced preoperative FECD and cataract grades were as- sociated with a higher incidence of severe corneal edema, but neither of these factors was shown to increase the incidence of clinically signifi- cant corneal decompensation. This study seeks to resolve pro- posed benefits of FLACS compared with standard phacoemulsification in eyes with FECD. It has been sug- phacoemulsification versus femtosecond with Fuchs' endothelial corneal dystrophy" Outcomes of conventional phacoemulsification versus femtosecond laser-assisted cataract surgery in eyes with Fuchs' endothelial corneal dystrophy Dagny Zhu, MD, Parth Shah, BS, William Feuer, MS, Wei Shi, MS, Ellen Koo, MD J Cataract Refract Surg. 2018;44(5). Article in press. Purpose: To compare outcomes in eyes with Fuchs' endothelial corneal dystrophy (FECD) following standard phacoemulsification versus femtosecond laser-assisted cataract surgery (FLACS). Setting: Tertiary referral academic center Design: Retrospective cohort study Methods: Charts from patients diagnosed with FECD who underwent phacoemulsification cataract surgery at the Bascom Palmer Eye Institute between January 1, 2014 and January 1, 2017 were reviewed. The institutional review board (IRB) of University of Miami Human Subjects Research Office approved the study protocol. Complicated surgeries and cases with concurrent keratoplasty, prior keratoplasty or glaucoma surgery, or follow-up time less than 3 months were excluded. The severity of endothelial disease and cataract density were graded based on documented slit lamp examination. Best corrected visual acuity (BCVA), central corneal thickness (CCT), and corneal edema at each visit were analyzed. Clinically significant corneal decompensation was defined by corneal edema with BCVA worse than 20/50 lasting greater than 3 months and/or any case resulting in keratoplasty. Results: A total of 207 eyes from 207 patients (64 FLACS and 143 conventional) were included. Demographics, follow-up time (mean 30 months), baseline CCT, corneal guttata severity, and cataract density were similar between groups (p>0.05). Preoperative BCVA was one line better for FLACS (p<0.05). The proportion of cases progressing to clinically significant decompensation (13%) was similar between groups (p>0.05). Univariate Cox survival analysis also found no difference (hazard ratio 1.0, 95% CI 0.4–2.7, p=0.96). Conclusions: Compared to conventional phacoemulsification, FLACS did not lower the rate of corneal decompensation in eyes with mild to moderate FECD. Despite the technological innovation of FLACS, it has been the challenge of clinicians to define the precise role of this expensive adjunct to cataract surgery.

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