10 EyeWorld Asia-Pacific | December 2024 Phaco vs. Femto by Nic J. Reus, MD, PhD, FEBOS-CR Phaco A surgeon uses a keratome, capsulorhexis foreceps, and a phacoemulsification handpiece to perform a conventional cataract surgery (CCS). It relies heavily on the surgeon’s skill and precision as it involves several manual steps, including corneal incisions, capsulorhexis, hydrodissection, lens fragmentation, lens emulsification, and intraocular lens (IOL) implantation. Despite its manual nature, CCS is renowned for its reliability and efficiency, yielding excellent visual outcomes with low complication rates. However, the manual aspects of the procedure can lead to variations in results, particularly among less experienced surgeons. Femtosecond laser-assisted cataract surgery (FLACS) represents a more recent advancement, utilizing laser technology to automate several key steps, such as incisions, capsulotomies, and lens fragmentation. Despite this innovation, hydrodissection, lens emulsification, and IOL implantation remain manual processes. The primary advantage of FLACS is its precision, facilitating uniform capsulotomies, and reducing the use of energy during lens fragmentation. Nevertheless, the clinical significance of this increased precision is debated, as CCS typically achieves excellent outcomes for most patients. Surgically-Induced Astigmatism Various studies have investigated the clinical outcomes of CCS versus FLACS. A meta-analysis by Kolb et al. (2020) found no significant difference in surgically-induced astigmatism between the two techniques, indicating that both methods yield similar outcomes in corneal astigmatism post-surgery, an important consideration for patients seeking precise refractive results. Capsulorhexis and Capsulotomy A notable distinction between the two techniques is the quality of capsulorhexis in CCS compared to the capsulotomy in FLACS. The laser technology in FLACS creates a perfectly round and centered opening, while the manual creation of capsulorhexis by the surgeon in CCS often results in more variability. However, the clinical relevance of this distinction remains debatable. Even manual capsulorhexis creation has been shown to yield an accurate postoperative axial position, tilt, and centration of the IOL (Findl, 2017). Only eyes with a severely malformed capsulorhexis, typically associated with inexperienced surgeons, show a slightly decentered IOL. Refractive Outcomes Another major concern for patients undergoing cataract surgery is the refractive outcome. According to the meta-analysis by Kolb et al. (2020), there is no significant difference in the spherical equivalent (SE) between CCS and FLACS, suggesting that both techniques deliver comparable results in correcting vision. Endothelial Cell Loss One significant advantage of FLACS is the reduced energy required during lens fragmentation. Using less phaco energy may help minimize corneal endothelial cell damage, which is critical for maintaining corneal clarity after surgery. However, meta-analyses, including one by Wang et al. (2023), indicate that endothelial cell loss is comparable between CCS and FLACS. This suggests that while FLACS uses less energy, it may not necessarily provide better corneal protection than CCS. FEATURE Pathways to Precision and Perfection – Phaco vs. Femto
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