Femtosecond laser-assisted versus phacoemulsification for cataract extraction and intraocular lens implantation: clinical outcomes review.

PURPOSE OF REVIEW: Femtosecond laser-assisted cataract surgery (FLACS) has gained popularity in recent years with the new technology suggesting potential improvements in clinical and safety outcomes over conventional phacoemulsification cataract surgery (PCS). A decade since the advent of FLACS has given time and experience for laser technology to develop in maturity, and better quality evidence to become available. This review evaluates current evidence on the clinical and safety outcomes for FLACS in comparison to PCS. RECENT FINDINGS: FLACS technology continues to improve and with it our confidence in tackling more complex patient indications. Concurrently other new technologies such as precision pulse capsulotomy also look to deliver the biomechanically ideal 5.2 mm capsulotomy, particularly as there remain suggestions from large studies and meta-analyses of raised capsular complications with FLACS compared with PCS and IOL technology responding to advantages of a consistent capsulotomy. Visual benefits of FLACS over and above PCS also remain to be conclusively demonstrated, with equivalence but not superiority. Economic modelling continues to indicate that FLACS remains 'not' cost-effective. SUMMARY: FLACS can be considered non-inferior to conventional PCS in term of safety and clinical outcomes. However, FLACS has yet to demonstrate an overall cost-benefit to the patient.

A Comparative Cohort Study of Visual Outcomes in Femtosecond Laser-Assisted versus Phacoemulsification Cataract Surgery.

PURPOSE: To evaluate visual outcomes after femtosecond laser-assisted cataract surgery (LCS) with phacoemulsification cataract surgery (PCS). DESIGN: Prospective, multicenter, comparative case series. PARTICIPANTS: Consecutive patients undergoing femtosecond LCS or PCS with intraocular lens insertion. METHODS: A total of 1876 eyes of 1238 patients (422 male and 772 female) who underwent cataract surgery between January 2012 and June 2014 were included in the study: 1017 eyes from center A and 859 eyes from center B. Cases underwent clinico-socioeconomic selection. Patients with absolute LCS contraindications were assigned to PCS; otherwise, all patients were offered LCS and elected on the basis of their decision to pay (the out-of-pocket cost for LCS). Demographic and postoperative data were collected to determine differences between groups. MAIN OUTCOME MEASURES: Six-month postoperative visual and refractive outcomes. Masked subjective refractions were performed 2 to 6 months postoperatively. RESULTS: There were 988 eyes in the LCS group and 888 eyes in the PCS group. Baseline best-corrected visual acuity (BCVA) was better in LCS compared with PCS (20/44.0 vs. 20/51.5; P < 0.0003). Preoperative surgical refractive aim differed significantly between groups (LCS -0.28 vs. PCS -0.23; P < 0.0001). More patients who received LCS had Toric lenses implanted compared with PCS (47.4% vs. 34.8%; P < 0.0001). Postoperative BCVA was better after LCS (20/24.5 vs. 20/26.4; P = 0.0003) with a greater proportion of LCS cases achieving BCVA >20/30 (LCS 89.7% vs. PCS 84.2%; P = 0.0006) and 20/40 (LCS 96.6% vs. PCS 93.9%; P = 0.0077). However, PCS cases had more letters gained compared with LCS cases (13.5 vs. 12.5 letters; P = 0.0088), reflecting baseline BCVA differences. Mean absolute error was higher in LCS compared with PCS (0.41 diopters [D] vs. 0.35 D; P < 0.0011). The percentage of eyes within 0.5 D of error from preoperative aim refraction was higher in the PCS group (LCS 72.2% vs. PCS 82.6%; P < 0.0001). CONCLUSIONS: Femtosecond LCS did not demonstrate clinically meaningful improvements in visual outcomes over conventional PCS.

Visual outcomes with femtosecond laser-assisted cataract surgery versus conventional cataract surgery in toric IOL insertion.

BACKGROUND: To evaluate the visual outcomes of femtosecond laser-assisted cataract surgery (LCS) compared with phacoemulsification cataract surgery (PCS) in patients undergoing Toric IOL insertion. DESIGN: A non-randomized, single surgeon, prospective, comparative cohort case series PARTICIPANTS: Patients undergoing LCS and PCS between January 2012 and July 2014 at a single center. METHODS: The LCS group underwent femtosecond laser pretreatment for the anterior capsulotomy and lens fragmentation. Otherwise standard phacoemulsification surgery and foldable toric intraocular lens insertion proceeded. MAIN OUTCOME MEASURES: Best corrected visual acuity (BCVA), uncorrected visual acuity (UCVA), pre and post operative cylinder and mean absolute refractive error. RESULTS: A total of 418 eyes from 323 patients were included in the study; with 95 eyes in the PCS group and 323 in the LCS group. There were 243 (75.5%) LCS eyes with a pre-operative BCVA of 20/40 or better and 54 (56.8%) in the PCS group (p < 0.001). For post-operative BCVA, 315 (97.5 %) LCS and 81 (85.3%) PCS eyes had a BCVA of 20/40 or better (p = <0.001). However, there was no significant difference for change in BCVA between the groups (mean gain in EDTRS letter 11.0 for LCS and 10.3 for PCS p = 0.64) or in MAE (mean 0.56D PCS vs 0.65D LCS p = 0.18). CONCLUSION: In patients receiving toric intraocular lenses, there is similar improvement in terms of letters gained with LCS and PCS. Overall, there is no additional benefit for patients undergoing LCS in this cohort.

Bilateral maculopathy associated with sertraline.

OBJECTIVE: We report a rare case of bilateral maculopathy that developed with the initiation of sertraline. METHODS: We conducted a case report and review of the literature. RESULTS: A 23-year-old man rapidly developed maculopathy with associated visual blurring after the initiation of sertraline. Treatment was ceased with the patient subsequently reporting mild improvement in visual symptoms. CONCLUSIONS: Maculopathy associated with sertraline use has yet to be established and recognized as an adverse side effect. With only one previous reported case in the literature, this condition requires further awareness.

Influence of Retinal Pathology on the Reliability of Macular Thickness Measurement: A Comparison Between Optical Coherence Tomography Devices.

BACKGROUND AND OBJECTIVE: To evaluate the repeatability, reliability, and comparability of macular thickness measurements between three optical coherence tomography (OCT) machines in healthy eyes, eyes with diabetic macular edema (DME), and eyes with neovascular age-related macular degeneration (nAMD). PATIENTS AND METHODS: Twenty-three eyes with DME, 26 eyes with nAMD, and 24 healthy eyes as controls were evaluated. Scans were performed using the swept-source Triton (Topcon, Tokyo, Japan), the spectral-domain Cirrus (Carl Zeiss Meditec, Dublin, CA), and the Spectralis (Heidelberg Engineering, Heidelberg, Germany) machines. Scans were evaluated for central macular thickness (CMT), presence of segmentation and fixation imaging artifacts (IA), re-scan reliability, and agreement between machines and groups. RESULTS: Mean CMT was significantly different between all OCT machines in all groups (P < .01 for all comparisons). Manually correcting IA did not alter these results. There was good scan repeatability among healthy and DME eyes for each machine, but poor repeatability among the nAMD group with the Spectralis (P = .038). IA were significantly increased in the presence of pathology. CONCLUSIONS: There is poor agreement of CMT measurement between OCT machines in healthy eyes and those with DME and nAMD. DME and nAMD have a significant effect on the rate of IA in scans. Care is required when interpreting measurements from different OCT devices in clinical practice and research settings. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:319-325.].

The role of aflibercept in the management of diabetic macular edema.

Diabetic macular edema (DME) represents one of the leading causes of visual impairment in working-age adults. Although there are several proven treatments available for this condition, pharmacotherapy through the use of intravitreal antivascular endothelial growth factor agents has revolutionized the management of DME over the past decade with superior outcomes compared to laser therapy. This review summarizes the pathophysiology and available treatment options for the management of DME, with an emphasis on the efficacy and safety profile of a single particular intravitreal antivascular endothelial growth factor agent, aflibercept.

Cystoid macular edema after femtosecond laser-assisted versus phacoemulsification cataract surgery.

PURPOSE: To evaluate the incidence of postoperative clinical cystoid macular edema (CME) associated with femtosecond laser-assisted cataract surgery (Catalys laser system) versus phacoemulsification cataract surgery. SETTING: Launceston Eye Institute, Launceston, Tasmania, Australia. DESIGN: Nonrandomized, single-surgeon, prospective, comparative cohort case series. METHODS: Patients who had femtosecond laser-assisted cataract surgery and phacoemulsification cataract surgery between March 2012 and July 2014 were included in the study. The femtosecond laser-assisted cataract surgery group had anterior capsulotomy, lens fragmentation, with or without corneal incisions via femtosecond laser pretreatment. Standard phacoemulsification surgery and foldable acrylic intraocular lens insertion proceeded in all cases. All patients received topical nonsteroidal drops commencing 2 days preoperatively and continuing for 4 weeks postoperatively. The incidence of postoperative clinical CME (confirmed by optical coherence tomography) and comparison between groups were measured. The main outcome measure was the clinical CME rates. RESULTS: Of the eyes, 833 had femtosecond laser-assisted cataract surgery amd 458 had standard phacoemulsification cataract surgery. Both groups had similar baseline parameters. There were 7 cases of postoperative CME (0.8%) in the femtosecond laser-assisted cataract surgery group compared to 1 case (0.2%) in the phacoemulsification cataract surgery group, highlighting a trend toward greater cystoid macular edema in the femtosecond laser-assisted cataract surgery group. This correlated with a change in laser treatment speed (due to a software upgrade), suggesting that retinal safety thresholds need further careful analysis. CONCLUSION: Increased CME might be a subthreshold retinal injury safety signal after femtosecond laser pretreatment and warrants further study. FINANCIAL DISCLOSURE: There are no financial or conflicts of interest for any author.

Femtosecond laser-assisted cataract surgery versus standard phacoemulsification cataract surgery: outcomes and safety in more than 4000 cases at a single center.

PURPOSE: To compare the intraoperative complications and safety of femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery. SETTING: Single center. DESIGN: Prospective consecutive comparative cohort case series. METHODS: Eyes had femtosecond laser-assisted cataract surgery (study group) or phacoemulsification (control group) by 1 of 5 surgeons. The technique comprised manual corneal incisions and capsulorhexis or laser-assisted anterior capsulotomy, lens fragmentation, corneal incisions, phacoemulsification, and intraocular lens implantation. RESULTS: The study group comprised 1852 eyes and the control group, 2228 eyes. Patient demographics were similar between groups. There was a significant improvement in vacuum/docking attempts, surface recognition adjustments, treatment, and vacuum time during the laser procedure in the study group. Anterior capsule tears occurred in 1.84% of eyes in the study group and 0.22% of eyes in the control group (P < .0001). There was no difference in the incidence of anterior capsule tears between the first half and second half of laser-assisted cases. Anterior capsulotomy tags occurred in 1.62% study group eyes. There was no significant difference in posterior capsule tears between the 2 groups (0.43% versus 0.18%). The incidence of significant intraoperative corneal haze and miosis was higher and the effective phacoemulsification time significantly lower in the study group (P < .001). CONCLUSIONS: Significant intraoperative complications likely to affect refractive outcomes and patient satisfaction were low overall. The 2 cataract surgery techniques appear to be equally safe. Although anterior capsule tears remain a concern, the safety of femtosecond-assisted cataract surgery in terms of posterior capsule complications was equal to that of phacoemulsification. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.