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Published on: September 16, 2025
Randomized Controlled Trial Comparing Femtosecond Laser-Assisted with Conventional Phacoemulsification on Dense
Soon-Phaik Chee1, Younian Yang2, Melissa H Y Wong3
1Singapore National Eye Centre, Singapore; Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cataract Research Team, Singapore Eye Research Institute, Singapore; Department of Ophthalmology & Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore.
Purpose:
To compare the benefit of femtosecond laser-assisted cataract surgery (FLACS) versus phacoemulsification (PE) and 2 fragmentation patterns in managing dense cataracts.
Design:
Randomized controlled trial.
Methods:
Patients with nuclear opacity (NO) grade >5 (Lens Opacities Classification System III) were enrolled at the Singapore National Eye Centre. Patients who were unsuitable for FLACS, whose corneal endothelial cell count (ECC) was <1,500 cells/mm2, or had cataracts with additional complexities were excluded from the study. Eyes were randomized to PE, 600 μm grid (FLACSg), or 16-segment fragmentation (FLACS16) in 2:1:1 ratio. The Victus (Bausch & Lomb) laser platform and in situ phacoemulsification chop technique was used. Data for patient demographics, preoperative, and 1 month postoperative best-corrected visual acuity (BCVA), ECC, effective phacoemulsification time (EPT), and perioperative complications were collected. Outcome measurements were the loss of ECC at 1 month and EPT.
Results:
Ninety-three patients were randomized to PE (48), FLACSg (22), and FLACS16 (23). Majority were Chinese (87; 93.5%). Mean age was 74.3 ± 8.8 years of age. Cataracts were mostly graded as NO 5-6 (49; 61.3%). EPT among treatment arms was not different (P = .097, one-way ANOVA) but was significantly higher for NO >6 than NO <6 (P < .001, general linear model). ECC loss was significantly less in FLACSg than in PE (P = .018, Bonferroni correction). Mean 1-month postoperative LogMAR BCVA (0.23 ± 0.20) was significantly better than preoperative BCVA (1.02 ± 0.85; P < .001, paired t test) but not different between PE and FLACS.
Conclusions:
FLACSg but not FLACS16 significantly lowered the mean ECC loss during phacoemulsification in dense cataracts.
