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FLACS vs phacoemulsification in shallow anterior chambers: systematic review and meta-analysis
Shih-Heng Hung1, Chiao-Hsin Lan, Ya-Hsin Yao
1From the Department of Ophthalmology, Show Chwan Memorial Hospital, Changhua, Taiwan (Hung); Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan (Lan); Department of Ophthalmology, College of Medicine, National Defense Medical University, Taipei, Taiwan (Yao, Lu, Chen, Yen); Department of Ophthalmology, Tri-Service General Hospital, National Defense Medical University, Taipei, Taiwan (Yao, Lu, Chen, Yen); Department of General Medicine, Tri-Service General Hospital, National Defense Medical University, Taipei, Taiwan (Chiu).
Topic:
To evaluate the efficacy and safety of femtosecond laser-assisted cataract surgery (FLACS) vs conventional phacoemulsification in eyes with shallow anterior chambers or primary angle-closure disease, with endothelial cell loss (ECL) as the primary outcome (PROSPERO: CRD420251274747).
Clinical Relevance:
Shallow anterior chambers pose unique surgical challenges during phacoemulsification, placing the corneal endothelium at increased risk of damage. This population, disproportionately prevalent in Asia, is expected to grow substantially with aging demographics, underscoring the need for optimized surgical strategies.
Methods:
MEDLINE, Embase, and Cochrane CENTRAL were searched through January 2026. Randomized controlled trials and observational studies comparing FLACS with conventional phacoemulsification were included. Risk of bias was assessed using Cochrane Risk of Bias 2 tool and Newcastle-Ottawa Scale. Pooled estimates were calculated using random-effects models; certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework.
Results:
6 studies (505 eyes) were analyzed. FLACS was associated with lower ECL (mean difference [MD] -4.97%; 95% CI -8.27 to -1.67; P = .003; I2 = 98%) and cumulative dissipated energy (MD -2.47; 95% CI -3.64 to -1.30; P < .001; I2 = 14% in sensitivity analysis). FLACS was associated with 60% lower odds of early postoperative complications (odds ratio 0.40; 95% CI 0.23-0.68; P < .001; I2 = 0%). Visual outcomes were comparable.
Conclusions:
FLACS was associated with fewer early postoperative complications, supported by moderate-certainty evidence, and with lower ECL and ultrasound energy, although the magnitude of these benefits remains uncertain on low-certainty evidence.
