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The Catalys Precision Laser System with a liquid-optics patient interface (Abbott Medical Optics, Inc.) was used in the
study group. This diode-pumped solid-state femtosecond
laser operates at a wavelength of 1030 nm and pulse duration
of 600 fs. The laser settings were consistent for the duration of
the study. The software versions were up to date at the time of
the study. Corneal incision modules were installed with a software upgrade in December 2012, which reduced the time
taken for anterior capsulotomy. For corneal incisions, the
main wound and 2 side-port settings, respectively, were as follows: limbal offsets 0.3 mm and 0.4 mm, width 2.7 mm and 1.3
mm, length 1.8 mm and 1.2 mm, and pulse energy 5 mJ and 6
mJ. The other settings were anterior plane depth 40%, posterior
plane depth 70%, anterior side-cut angle 75 degrees, and posterior side-cut angle 45 degrees for the main wound and the
side port. For anterior capsulotomy, the incision depth was
600 mm, the horizontal spot spacing was 5 mm, the vertical
spot spacing was 10 mm, and the pulse energy was 4 mJ. For
lens fragmentation, the posterior capsule safety zone was
500 mm, the horizontal spot spacing was 10 mm, the vertical
spot spacing was 40 mm, and the pulse energy was 8 mJ anteriorly and 10 mJ posteriorly.
Preoperative Assessment
Surgical Technique
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Variable
Mean vacuum
attempts (n)
Mean docking
attempts (n)
OCT adjustments, n (%)
Mean treatment time (s)
Vacuum time (min:sec)
First Half
of Cases
Second Half
of Cases
P Value
1.25 G 0.61
1.26 G 0.58
1.35 G 0.69
1.28 G 0.68
91 (12.1)
43 (5.7)
60.8 G 14.02 54.13 G 14.76
3:27 G 0:43 3:23 G 0:44
NS
.04
.0001
.0001
NS
Means G SD
NS Z not significant; OCT Z optical coherence tomography
Statistical Analysis
Statistical analyses were performed using SPSS software
(version 19, International Business Machines Corp.). For
comparison of baseline demographics and clinical characteristics between groups, categorical data were analyzed using
the Fisher exact test and continuous data using paired t tests.
Differences were accepted as significant when the P value
was less than 0.05.
RESULTS
The study evaluated 4080 eyes, 1852 eyes in the study
group and 2228 eyes in the control group. Patient demographics and baseline characteristics were similar between groups. In particular, there was no significant
between-group difference in ocular comorbidities, intraoperative pupil size, cataract grade, or age of patients.
The mean age was 73.5 years G 9.5 (SD) in the study
group and 72.6 G 9.6 years in the control group. Nucleus
staging using the Scheimpflug system showed a mean
cataract grade of 2.81 G 0.65 in the study group and
2.80 G 0.71 in the control group. One thousand thirtyseven eyes (56%) in the study group and 1225 eyes
(55%) in control group were women.
All aspects of the laser procedure improved with
surgeon experience. There was a statistically significant improvement in docking attempts, image/OCT
surface-recognition adjustments, and treatment time
during the laser procedure in the second half of cases
(Table 1). Some improvements reflected the benefits
of software upgrades during the study.
Table 2 shows the intraoperative complications. The
incidence of anterior capsule tears and anterior capsulotomy tags was statistically significantly higher in the
study group than in the control group (P ! .0001).
Although the incidence of posterior capsule tears was
higher in the study group, the difference between
groups was not statistically significant. One case of anterior capsule tear in each group extended to the posterior
capsule, requiring anterior vitrectomy; the remaining
cases proceeded uneventfully with IOL placement in
the bag. The incidence of significant intraoperative
corneal haze affecting the surgical field view and intraoperative miosis was statistically significantly higher in
the study group than in the control group (P ! .001).
The effective phacoemulsification time was statistically
significantly lower in the study group (P ! .0001). There
were no cases of posterior lens dislocation.
There was no difference in the incidence of anterior
or posterior capsule tears between the first half and
second half of femtosecond laserassisted cases
(c2(1) Z 1.3, P Z .3), suggesting the learning curve
had little effect on these parameters.
DISCUSSION
This large prospective single-center comparative
cohort study evaluated the safety and learning curve
of femtosecond laserassisted cataract surgery. We
found a statistically significantly higher rate of anterior capsule tears in the femtosecond laserassisted
cataract surgery group, and this was not related to
the learning curve. There was, however, no betweengroup statistically significant difference in complications such as posterior capsule tear and dropped
nucleus, which might be considered more clinically
relevant for refractive outcomes and patient satisfaction. At present, there is a need for surgical benchmarks with regard to laser cataract surgery
complications so surgeons can better inform their
patients of the risks and benefits of femtosecond
laserassisted cataract surgery.
Evidence-based guidelines for phacoemulsification
cataract surgery suggest that a capsule complication
rate of less than 2.0% should be achievable.9 The
incidence of anterior capsule tear in our study was
below this figure in the femtosecond laserassisted
group (1.84%) but was statistically significantly higher
than in our phacoemulsification cataract surgery
benchmark (0.22%) after 2228 cases. Published peer-
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Phacoemulsification (n Z 2228)
P Value
21 (1.13)
30 (1.62)
34 (1.84)
8 (0.43)
12 (0.65)
30 (1.65)
5 (0.27)
NA
1 (0.004)
5 (0.22)
4 (0.18)
1 (0.04)
14 (0.65)
1 (0.04)
NA
.0001
.0001
NS
.0009
.003
NS
complications. However, our results show a statistically significantly greater risk for anterior capsule
tears in femtosecond laserassisted cataract surgery
(1.84%) than in phacoemulsification cataract surgery
(0.22%). A case study of capsular block syndrome
(CBS)7 showed the potential for large volumes of intracapsular gas to cause posterior capsule rupture
during hydrodissection and hence was the first study
to report the differences in fluid volumes, fluidics, intracapsular dynamics, and their potential effect on intracapsular manipulations. Only 1 of our cases of
posterior capsule tear in the femtosecond laser group
occurred as a result of CBS and in the first handful of
cases performed by the surgeon. The surgeon was
able to remove the lens in the anterior segment plane;
this was followed by anterior vitrectomy and IOL implantation in the sulcus.
The safety of femtosecond laserassisted cataract
surgery has been reported in the short term.6 Early
studies of the short-term and long-term surgical outcomes are also emerging,2127 and there may be an effect of a learning curve that we did not identify in our
study.6,19 Further research of the effect of femtosecond
laserassisted cataract surgery on the postoperative
intraocular pressure, corneal edema, endothelial cell
count, and macular thickness may indicate whether
the reduction in phacoemulsification energy and
replacement with femtosecond laser energy will lead
to improved safety and better outcomes.
In conclusion, significant intraoperative complications that are likely to affect refractive outcomes and
patient satisfaction were low in both groups. Femtosecond laserassisted cataract surgery appears to be
as safe as conventional phacoemulsification cataract
surgery. Although anterior capsule tears remain a
concern, the safety of femtosecond laserassisted cataract surgery and phacoemulsification cataract surgery
was the same in terms of posterior capsule
complications.
WHAT WAS KNOWN
Femtosecond laserassisted cataract surgery is as safe
and effective as conventional phacoemulsification cataract surgery.
WHAT THIS PAPER ADDS
Anterior capsule tears remain a concern; however, the
incidence of posterior capsule complications was similar
between the 2 surgical techniques.
The effect of a learning curve on intraoperative complications was minimal.
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