Conventional Versus Laser-Assisted Cataract Surgery

Taking into consideration effectiveness, cost-effectiveness, and versatility, Joaquín Fernández MD, PhD highlighted reasons surgeons may prefer conventional cataract surgery, but he emphasised that he does not rely on it exclusively.

Speaking at the 2025 ASCRS meeting in Los Angeles, Professor Fernández reviewed the evidence supporting his practices.

“We are people of science, and we have to evaluate our decisions based on scientific evidence,” Prof Fernández said.

Information about the real-world effectiveness of the two procedures came from recent meta-analyses. Authors of a 2023 Cochrane meta-analysis, which reviewed 42 studies, identified some differences between conventional cataract surgery and a femtosecond laser-assisted approach in various endpoints, concluding any difference in postoperative visual outcomes would expected to be small.¹ Another meta-analysis published in 2025 of 41 studies also found no difference between the procedures in visual outcomes at middle-term follow-up and concluded both are safe and effective.²

“There are some differences between the two procedures, such as the consistency of the shape and size of the capsulotomy; and there may be differences in safety, but these are minimal. When it comes to effectiveness, final visual acuity and quality of vision are the same,” Prof Fernández said.

While multiple groups have undertaken economic evaluations of femtosecond laser-assisted cataract surgery, the key when reviewing this research is to consider the type of analysis, the perspective under investigation, and the data source, Prof Fernández said.

He explained that economic evaluations can use a value-health concept linked to the individual or a cost-utility approach linked to health systems. The evaluation can be orchestrated from the perspective of the patient, provider, payer, or society, and the findings can differ from country to country.

Prof Fernández illustrated this information by discussing several studies. Although most research in this area finds that a laser-assisted approach is not cost-effective, an analysis conducted by Prof Fernández and colleagues assessing the cost-effectiveness of treating low corneal astigmatism from the patient’s perspective determined that in situations where a spherical IOL is implanted, correcting astigmatism with femtosecond laser-arcuate keratotomies was generally the most cost effective.³

When it comes to versatility, Prof Fernández mentioned a variety of situations where using a conventional approach could be safer or where using a femtosecond laser may not be feasible. The examples included eyes with tremor, dense or white cataracts, zonular weakness or instability, post-traumatic cataract, or certain anterior segment abnormalities. However, he stated that he considers a femtosecond laser-assisted approach the better option in eyes with a shallow anterior chamber.

“We must also consider that phacoemulsification is more adaptable,” Prof Fernández said. “It can be used in high-resource settings with advanced machines and in low- and middle-income countries where manual small-incision cataract surgery or only basic phaco systems are used.”

He mentioned that in a world where there is growing concern about the environmental impact arising from the healthcare sector, sustainability is another issue necessary to consider. Currently, however, evidence comparing the sustainability of conventional cataract surgery to femtosecond laser-assisted methods is limited.

“Key questions that require further investigation include the environmental footprint associated with disposable versus reusable equipment, energy consumption differences between procedures, and long-term resource use, including the frequency of complications or reoperations that may indirectly impact sustainability,” Prof Fernández said.

Joaquín Fernández Pérez MD, PhD is CEO and Medical Director in the Ophthalmology Department at Qvisión in Vithas Virgen del Mar Hospital, Almería, Spain. joaquinfernandezoft@qvision.es

1. Narayan A, Evans JR, O’Brart D, et al. “Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery,” Cochrane Database Syst Rev, 2023; 6(6): CD010735.

2. Song X, Li L, Zhang X, Ma J. “Comparing the efficacy and safety between femtosecond laser-assisted cataract surgery and conventional phacoemulsification cataract surgery: systematic review and meta-analysis,” Can J Ophthalmol, 2025; 60(1): e1–e10.

3. Ginel J, Rodríguez-Vallejo M, Piñero D, et al. “Cost-effectiveness of low-astigmatism correction with toric or spherical intraocular lenses combined with corneal incisions: an economic evaluation,” J Cataract Refract Surg, 2024; 50(10): 1012–1019.