Steps Of Cataract Surgery Research Articles

Manual-delineation and dissection technique for posterior polar cataract

In posterior polar cataract (PPC), the posterior capsule is weak or dehiscent. This can lead to posterior capsular rent at any time during cataract surgery, leading to complications. Various techniques have been used to manage such cataracts, and modifications are advised at each and every step of cataract surgery. We describe a new technique in which a blunt chopper is used to manually delineate the epinucleus from the nucleus at 360 degrees, and the nucleus is chopped and removed by phacoemulsification. Then, the chopper is inserted in the plane between the capsule and the epinucleus, and manual dissection is performed, followed by rotation and pushing it centrally. This epinucleus that is separated is aspirated simultaneously. Thus, with no pressure fluctuations and undue stress on the posterior capsule from the fluid jets, we manage to do surgery in tricky cases of PPCs successfully using manual delineation and dissection.

Intraocular Lens Unfurling Time Exponentially Decays with Increased Solution Temperature.

Intraocular lens (IOL) unfurling can be a rate-limiting step in cataract surgery, limiting operative efficiency. Furthermore, inefficient unfurling has important implications for clinical outcomes. We examine the effects of solution temperature on IOL unfurling time using three in vitro models of the ocular environment. IOLs were injected into a 6-well plate filled with balanced salt solution (BSS), dispersive ophthalmic viscoelastic device (OVD), or cohesive OVD. Experiments were also performed in a plastic eye filled with dispersive or cohesive OVD. IOL unfurling time was recorded against the temperature of the respective solution. IOL unfurling time decayed exponentially as solution temperature increased in all experiments, including the BSS-filled 6-well plate, the OVD-filled 6-well plate, and the OVD-filled plastic eye. IOLs failed to unfurl within 10 min at 10°C, below the glass transition temperature of the tested IOLs. Increasing solution temperature from 20°C to 30°C decreases IOL unfurling by greater than 2 min. Further heating to 40°C did not significantly decrease IOL unfurling time. Increased solution temperature rapidly decreases IOL unfurling time in vitro. IOLs do not unfurl within a clinically acceptable timeframe at or below their glass transition temperature. Increased BSS and/or OVD temperature may be a potential method to decrease IOL unfurling time in cataract surgery. However, future research is needed to elucidate potential consequences of warmed BSS and/or OVD on post-operative outcomes. This study demonstrates the potential for temperature regulation to decrease cataract surgery operative time and provides preliminary evidence to justify future clinical validation of this relationship.

Intraoperative Complication Rates in Cataract Surgery After Resuming Surgery Following the COVID-19 Shutdown.

To evaluate surgeon performance and intraoperative complication rates of cataract surgery after resumption of elective surgeries following the operating room (OR) shutdown from the coronavirus disease 2019 (COVID-19) pandemic. Subjective surgical experience is also evaluated. This is a retrospective comparative study which analyzes cataract surgeries performed at an inner city, tertiary academic center. Cataract surgeries were categorized into Pre-Shutdown (January 1-March 18, 2020), and Post-Shutdown, for all cases which occurred after surgeries resumed (May 11-July 31, 2020). No cases were performed between March 19 and May 10, 2020. Patients undergoing combined cataract and minimally invasive glaucoma surgery (MIGS) were included, but MIGS complications were not counted as cataract complications. No other combined cataract-other ophthalmic surgeries were included. A survey was used to gather subjective surgeon experience. A total of 480 cases (n=306 Pre-Shutdown and n=174 Post-Shutdown) were analyzed. Although there was a higher frequency of complex cataract surgeries performed Post-Shutdown (5.2% vs 21.3%; p<0.00001), complication rates before versus after the shutdown were not statistically significant (9.2% vs 10.3%; p=0.75). Phacoemulsification was the step of cataract surgery in which residents were most concerned about when returning to the OR. After the surgical hiatus due to COVID-19, significantly more complex cataract surgeries were reported and surgeons reported higher general anxiety level when first returning to the OR. Increased anxiety did not lead to higher surgical complications. This study provides a framework to understand surgical expectations and outcomes for patients whose surgeons faced a prolonged two-month hiatus from cataract surgery.

A Novel Cost-Effective Simulation Model for Continuous Curvilinear Capsulorhexis.

IntroductionWe describe and validate a low-cost simulation model for practicing anterior lens capsule continuous curvilinear capsulorhexis (CCC).MethodsA simulation model for CCC was developed from widely available low-cost materials. Ophthalmologists attending the annual scientific meeting of the Research Institute of Ophthalmology, Giza, Egypt, were asked to perform a five CCC model task and then anonymously answer a questionnaire that assessed the realism and training utility of the model using a five-point Likert scale (1 = unacceptable, 2 = poor, 3 = acceptable, 4 = favorable and 5 = excellent).ResultsTwenty-seven ophthalmologists completed the task and the anonymous questionnaire. Overall, participants felt that the model simulated CCC step in cataract surgery well (mean: 3.5) and was comparable to other kinds of CCC simulation models (mean: 3.3). The model scored highly for its overall educational value (mean: 4.00) and for enlarging a small CCC (mean:3.7), while the feasibility of this model in practicing the management of a runaway leading edge of CCC scored 2.9.ConclusionThis model may provide an alternative method for training for CCC and other anterior lens capsule-related maneuvers. This option may be particularly helpful for residency training programs with limited access to virtual reality simulators or commercially available synthetic eye models.

Video-based assessment of intraoperative surgical skill.

Surgeons' skill in the operating room is a major determinant of patient outcomes. Assessment of surgeons' skill is necessary to improve patient outcomes and quality of care through surgical training and coaching. Methods for video-based assessment of surgical skill can provide objective and efficient tools for surgeons. Our work introduces a new method based on attention mechanisms and provides a comprehensive comparative analysis of state-of-the-art methods for video-based assessment of surgical skill in the operating room. Using a dataset of 99 videos of capsulorhexis, a critical step in cataract surgery, we evaluated image feature-based methods and two deep learning methods to assess skill using RGB videos. In the first method, we predict instrument tips as keypoints and predict surgical skill using temporal convolutional neural networks. In the second method, we propose a frame-wise encoder (2D convolutional neural network) followed by a temporal model (recurrent neural network), both of which are augmented by visual attention mechanisms. We computed the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and predictive values through fivefold cross-validation. To classify a binary skill label (expert vs. novice), the range of AUC estimates was 0.49 (95% confidence interval; CI = 0.37 to 0.60) to 0.76 (95% CI = 0.66 to 0.85) for image feature-based methods. The sensitivity and specificity were consistently high for none of the methods. For the deep learning methods, the AUC was 0.79 (95% CI = 0.70 to 0.88) using keypoints alone, 0.78 (95% CI = 0.69 to 0.88) and 0.75 (95% CI = 0.65 to 0.85) with and without attention mechanisms, respectively. Deep learning methods are necessary for video-based assessment of surgical skill in the operating room. Attention mechanisms improved discrimination ability of the network. Our findings should be evaluated for external validity in other datasets.

Recent developments in anterior capsulotomy for cataract surgery.

Successful anterior capsulotomy is an important step in cataract surgery. This article reviews the various anterior capsulotomy techniques available to surgeons to optimize the step, including those that have become available since the introduction of femtosecond-laser-assisted cataract surgery (FLACS). Studies comparing the relative advantages of each technique will be emphasized. Manual continuous curvilinear capsulorhexis (CCC) and FLACS remain the two most widely studied techniques for achieving anterior capsulotomy. Each technique has been shown to be effective for a wide range of patients and cataract surgery complications. Meta-analyses have shown that FLACS provides similar results to manual CCC for long-term cataract surgery outcomes. Several alternative methods for anterior capsulotomy have been described, which aim to provide some of the advantages of laser capsulotomy at a lower cost; among these, precision pulse capsulotomy (PPC) and selective laser capsulotomy (SLC) have been investigated the most in the literature so far. Cataract surgeons have an increasing number of techniques for anterior capsulotomy available. Manual CCC and FLACS remain the most widely used, and most well studied. The latest techniques, PPC and SLC, have shown promise in the few studies performed since they were introduced.

Femtosecond Laser Assisted Cataract Surgery: A Review

ABSTRACT Femtosecond laser assisted cataract surgery (FLACS) offers a level of precision, accuracy and customization that is not possible with manual phacoemulsification (MP). With the increase of patient expectations and premium intraocular lens utilization in the era of refractive cataract surgery, predictability and accuracy has become of utmost importance. FLACS has four main functions: creation of a consistently sized round capsulotomy, treatment of keratometric astigmatism with arcuate incisions, construction of clear corneal incisions, and fragmentation and/or softening of the lens. However, FLACS may have limitations due to suction loss, incomplete capsulotomy or poor pupillary dilation. Patient selection and surgeon experience is critical. This review article will focus on the various platforms available for FLACS, the steps in cataract surgery it can perform, and overall advantages and limitations of the technology.

Innovative intraocular lens loading magnified.

Cataract surgery continues to evolve and advance in terms of new technology and improved techniques, offering a final result of better visual quality and faster visual recovery for our patients. Intraocular lens (IOL) delivery into the eye is a critical step in cataract surgery. Currently, eye surgeons load the IOL into the cartridge under the operating microscope or ophthalmic assistants load the IOL under their own direct vision. Because ophthalmic assistants load the IOL unaided, the IOL may be mishandled and lead to challenges such as IOL slippage, breakage, or incorrect orientation. In order to overcome these challenges and facilitate the surgical process, here we describe a novel technique by introducing a magnifier to the surgical table to aid ophthalmic assistants during this crucial step in cataract surgery. This not only saves time but also improves precision while loading IOL into the cartridge during cataract surgery.

Objective assessment of intraoperative technical skill in capsulorhexis using videos of cataract surgery.

Objective assessment of intraoperative technical skill is necessary for technology to improve patient care through surgical training. Our objective in this study was to develop and validate deep learning techniques for technical skill assessment using videos of the surgical field. We used a data set of 99 videos of capsulorhexis, a critical step in cataract surgery. One expert surgeon annotated each video for technical skill using a standard structured rating scale, the International Council of Ophthalmology's Ophthalmology Surgical Competency Assessment Rubric:phacoemulsification (ICO-OSCAR:phaco). Using two capsulorhexis indices in this scale (commencement of flap and follow-through, formation and completion), we specified an expert performance when at least one of the indices was 5 and the other index was at least 4, and novice otherwise. In addition, we used scores for capsulorhexis commencement and capsulorhexis formation as separate ground truths (Likert scale of 2 to 5; analyzed as 2/3, 4 and 5). We crowdsourced annotations of instrument tips. We separately modeled instrument trajectories and optical flow using temporal convolutional neural networks to predict a skill class (expert/novice) and score on each item for capsulorhexis in ICO-OSCAR:phaco. We evaluated the algorithms in a five-fold cross-validation and computed accuracy and area under the receiver operating characteristics curve (AUC). The accuracy and AUC were 0.848 and 0.863 for instrument tip velocities, and 0.634 and 0.803 for optical flow fields, respectively. Deep neural networks effectively model surgical technical skill in capsulorhexis given structured representation of intraoperative data such as optical flow fields extracted from video or crowdsourced tool localization information.

Video recording and light intensity change analysis during cataract surgery using an animal model.

To estimate light exposure changes during cataract surgery through intraoperative images simulated from the "patient's perspective" using an animal model. In this experimental study, a 3-mm maculostomy was performed through the posterior globe's surface of 15 porcine eyes. Eyes were fixated to a glass slide and placed over an iPad camera. Video footage of a cataract surgery was obtained through the maculostomy for each eye, keeping light exposure parameters and focus constant. Seventy-five images, five from each eye, were extracted at pre-determined points, and mean gray value (MGV), a light intensity measure, was calculated. Differences in MGV between discrete surgical steps were evaluated using multiple one-sample t-tests. This technique allowed for the capture of a full-length cataract surgery through a 3-mm maculostomy. MGV range was 14.21-132.51. Light intensity was similar across surgeries and varied greatly through each procedure. A 24% decrease in MGV between post-hydrodissection and post-phacoemulsification stages was noted (difference - 18.36; 95% CI - 30.50 to - 6.22; p value = 0.006). A 22.4% decrease in light intensity was noted after phacoemulsification in comparison to the starting image (MGV difference - 16.78; 95% CI - 32.45 to - 1.12; p value: 0.0375). Light intensity was similar at the start and end of surgery (difference - 7.15; 95% CI - 19.35 to + 5.05; p value = 0.229). Light intensity changes through different steps of cataract surgery and may be minimal after phacoemulsification completion. This video and data may serve as informational and educational tools for surgeons and patients.

Wet Lab-Based Cataract Surgery Training Curriculum for the PGY 2/PGY 3 Ophthalmology Resident.

Studies have shown that structured cataract surgery training curricula are beneficial for resident surgeons-in-training, yet nearly one-third of US training programs do not have one, and public dissemination of said curricula are lacking. We created a microsurgical simulation center and accompanying structured training curriculum. Weekly lectures focused on the steps of cataract surgery, variations on technique, and complications. Each didactic was followed by a 1.5- to 2-hour time block with faculty supervision in the wet lab. Finally, to demonstrate proficiency, residents submitted a recorded video illustrating their competency within 1 week of the lecture. We reviewed videos and provided written feedback via a standardized form. Curriculum effectiveness was evaluated through formative feedback on the course itself and complication rates for resident-performed cataract surgery before and after implementation of the curriculum. The course was implemented in 4 consecutive academic years, allowing time for nine junior residents to participate in the course at least once before operating as a senior. The incidence of posterior capsule tears for senior residents decreased from 3.07% in the 4 years preceding curriculum implementation to 1.13% for the senior residents who completed the course at least once as juniors (p = .0571). Supervised wet lab sessions and submitted videos allowed faculty to identify surgically struggling residents early. Implementation of a cataract surgery training curriculum for junior ophthalmology residents provides a safe and effective environment to practice surgical techniques. Such a curriculum may decrease the complication rates of beginner surgeons.

Effect of increasing flow when grooving during phacoemulsification

To determine optimum flow settings on the Centurion Vision System during the grooving step in cataract surgery. John A. Moran Eye Center Laboratory, University of Utah, Salt Lake City, Utah, USA. Experimental study. Intact porcine lenses hardened by formalin and placed in a chamber designed to simulate the anterior chamber of the eye were used to test flow rate settings at 20mL/min, 40mL/min, and 60mL/min. Vacuum was set at 400mm Hg, longitudinal power at 80%, torsional power at 80%, and intraocular pressure at 50mm Hg. A balanced phaco tip with a 20-degree tip and a 30-degree bevel was used. Efficiency (time to groove the lens in half) was determined. Increasing flow from 20 to 40mL/min during grooving increased efficiency by 17% (P=.05), with no significant improvement shown at 60mL/min. A flow rate of 40mL/min was determined to be most efficient during the grooving step of cataract surgery. Further increases in flow rate showed no statistically significant improvement in efficiency, and with only 17% improvement flow rates less than 40mL/min might be almost as efficient and might be safer.

Capsule rupture and vitrectomy during phacoemulsification

Rupture of the posterior capsule can occur as one of the complications during phacoemulsification. The aim of this study was to determine whether the risk of capsule rupture depends on the surgeon's concentration or experience, time of day and season, the side to be operated on and anatomy of the eye as well as the frequency with which it can be expected. The patient collective was derived from patients who underwent cataract surgery by phacoemulsification between 2004 and 2014. All surgeries were performed by the same surgeon and constituted no primarily combined operations. Thereby, it was determined how many capsule ruptures occurred, with and without vitrectomy. There were so significant differences between the left or right eye, weekday or month. During the various surgical steps of cataract surgery, the occurrence of capsule rupture was only significantly more frequent at the time of capsule polishing. Compared to the results of other studies, the risk of complications was lower in the operation collective investigated in this study.

Resident Stress Level during Steps of Cataract Surgery

Purpose To investigate intraoperative stress levels using heart rate monitoring during each step of cataract surgery. Setting Single tertiary hospital. Design Observational study recording resident heart rate as a measure of acute stress level during cataract surgeries. Methods Emory ophthalmology postgraduate year (PGY) 3 and PGY-4 residents operating at Grady Memorial Hospital during the time period of the study were eligible to participate. Chest-strapped Bluetooth devices recorded heart rate during the surgeries. The mean, maximum, and minimum heart rates were then analyzed individually for the following steps of surgery: incisions, continuous curvilinear capsulorhexis, hydrodissection, nucleus disassembly, quadrant removal, cortical cleanup, intraocular lens insertion, and closure. Data collection started in April 2017 and ended in February 2018. Results Out of the 549 surgeries recorded, 427 yielded viable data. Across that dataset, quadrant removal had the highest adjusted mean heart rate value (90.3; 95% confidence interval [CI]: 82.9–97.7; p &lt; 0.0001), highest adjusted maximum heart rate value (97.3; 95% CI: 89.5–105.3; p &lt; 0.0001), and highest adjusted minimum heart rate value (82.1; 95% CI: 75.2–89; p &lt; 0.0001). Nuclear disassembly and incisions were second and third highest, respectively. Conclusions Quadrant removal, nucleus disassembly, and incisions are the three most stressful steps for resident surgeons. This knowledge should be applied to enhance the resident experience by emphasizing these steps during surgical preparation and training. Future studies using intraoperative heart rate monitoring may be warranted to better understand the resident and attending experience and ultimately improve surgical outcomes.

Conquering the White Cataract

We review clinical pearls in the evaluation and surgical management of white cataracts. Femtosecond laser-assisted cataract surgery is a newer technology that can aid in capsulorhexis creation, however the surgeon should be aware of the risk of incomplete capsulotomy creation in intumescent white cataracts. The surgeon should be fully prepared and anticipate challenges at every step of cataract surgery in these complex cases.

Teaching in the operating room: trends in surgical skills transfer in ophthalmology

Cataract surgery is arguably the most commonly performed operation in ophthalmology. Surgical skills transfer from experienced surgeons to resident surgeons is complicated by the fact that the teaching surgeon primarily acts as an observer rather than directly performing the procedure. Therefore, wet lab and simulator training are utilized to reduce the learning curve of the novice surgeons, which establishes tissue awareness, dexterity and muscle memory required to perform each step of the procedure, safely. Access to a wet lab and simulator environment is accomplished by establishing a surgical training curriculum in residency programs. In the operating room, topical anesthesia is a safe alternative for teaching cataract surgery. There are three well-described approaches to teaching individual steps of cataract surgery: forward, “backwards”, and deconstructed step-by-step instruction. Simulator training can be incorporated prior to live patient experience or integrated concurrently with learner presence in the operating room. The trend towards a competency-based instruction model has necessitated appropriate evaluation tools that include Objective Assessment of Skills in Intraocular Surgery (OASIS), Global Rating Assessment of Skills in Intraocular Surgery (GRASIS), and the International Council of Ophthalmology’s Ophthalmology Surgical Competency Assessment Rubrics (ICO-OSCAR). We review the literature on trends in surgical teaching in ophthalmology, with the focus on cataract surgery instruction to the novice surgeon.

Assessment of resident training and preparedness for cataract surgery

To assess which surgical teaching methods are used for residency surgical training and which methods residents find most useful. Wilmer Eye Institute, Baltimore, Maryland, USA. Retrospective observational cross-sectional study. A survey was developed and sent to residents at accredited ophthalmology training programs in the United States. The survey asked about demographics, program characteristics, surgical training methods, perceived initial preparedness, eventual competence, and difficulty with the steps of cataract surgery. The correlation between surgical training methods was compared with perceived preparedness, competence, and difficulty. One hundred sixteen residents completed the survey. Discussing surgical procedures with senior surgeons or using surgical simulators preoperatively improved resident-perceived surgical competency in several areas, such as paracentesis. Residents who had preoperative discussions with senior surgeons were statistically less likely to report difficulty with surgical procedures, such as performing a clear corneal incision. The presence of a supervised wet lab or surgical simulator in a residency was also associated with improved resident-perceived surgical competency. Educational resources, such as surgical simulators and supervised wet labs, tended to be associated with greater resident-perceived competency for steps in cataract surgery.

Dose and administration of intracameral moxifloxacin for prophylaxis of postoperative endophthalmitis

To review current and past practices of intracameral antibiotic administration for infection prophylaxis in cataract surgery; to review the benefits and liabilities of available prophylactic drugs, dosage determination, and administration protocols; and to devise an optimum dose and administration protocol for intracameral moxifloxacin. Humber River Hospital and the University of Toronto, Toronto, Ontario, Canada. Retrospective evaluation of treatment modality. This study consisted of a detailed review of the history, drugs, and methods of intracameral prophylaxis and microbiological and pharmacodynamics analysis of options. A review of potential drug sources and doses was performed and 1 drug, dose, and administration protocol was selected. The current method's adoption reasons are described followed by the authors' experience. A single infection in 3430 cases occurred with a moxifloxacin-resistant strain of Staphylococcus epidermidis when moxifloxacin 100 mcg in 0.1mL was used. Increasing the dose and changing the administration technique resulted in no infections in 4601 cases and no detrimental side effects or complications. Intracameral moxifloxacin prepared by dilution of 3cc moxifloxacin 0.5% (Vigamox) with 7cc balanced salt solution and with the administration of 0.3 to 0.4cc (450 to 600 mcg.) as thefinal step in cataract surgery via the side port after the main incision has been sealed and hydrated showed advantages over alternative intracameral antibiotic prophylactic methods, with minimum risk. Neither author has a financial or proprietary interest in any material or method mentioned.

Effectiveness of timely intraoperative iodine irrigation during cataract surgery.

To determine the antiseptic efficacy of timely intraoperative iodine irrigation during cataract surgery. A total of 198 eyes of 99 cataract surgery patients were studied. The eyes were randomly assigned to treatment with or without timely intraoperative iodine irrigation of the surgical field with an iodine compound equivalent to 0.33% povidone-iodine. In eyes in the timely intraoperative iodine irrigation group, the ocular surface was irrigated twice intraoperatively-before the initial incision and before insertion of the intraocular lens (IOL). The efficacy of the antiseptic treatment was evaluated by culture tests using scrapings of the surface of the sclerocornea and conjunctiva to the left of the incision and by broad-range real-time PCR for bacterial 16S ribosomal DNA using scrapings from the right side of the incision. Following intraoperative application of the iodine, bacteria were not detected in cultures of the samples. For the control eyes without timely iodine irrigation, cultures of samples from five and two eyes were positive before the initial incision and before IOL insertion, respectively. The bacterial DNA copy number before the initial incision was 1.7±0.5×103, which was significantly lower than that of the control eyes (1.7±0.6×104). For both groups of eyes, the bacterial DNA copy number was significantly lower before the IOL insertion depending on the time course. When the antiseptic effect of the iodine irrigation and time course on bacterial DNA copy number was analyzed using generalized mixed linear regression, both were found to be significantly effective. No significant intraoperative epithelial defect was observed. The postoperative corneal endothelial cell count did not differ significantly between the two groups of eyes. Timely iodine irrigation can serve as a simple and useful adjunctive disinfection step in cataract surgery.

Laser-assisted cataract surgery versus standard ultrasound phacoemulsification cataract surgery.

Cataract is the leading cause of blindness in the world, and cataract surgery is one of the most commonly performed operations in the Western world. Preferred surgical techniques have changed dramatically over the past half century with associated improvements in outcomes and safety. Femtosecond laser platforms that can accurately and reproducibly perform key steps in cataract surgery, including corneal incisions, capsulotomy and lens fragmentation, are now available. The potential advantages of laser-assisted surgery are broad, and include greater safety and better visual outcomes through greater precision and reproducibility. To compare the effectiveness of laser-assisted cataract surgery with standard ultrasound phacoemulsification cataract surgery by gathering evidence on safety from randomised controlled trials (RCTs). We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register) (2016, Issue 4), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to May 2016), EMBASE (January 1980 to May 2016), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to May 2016), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en) and the U.S. Food and Drugs Administration (FDA) website (www.fda.gov). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 10 May 2016. We included randomised controlled trials where laser-assisted cataract surgery was compared to standard ultrasound phacoemulsification cataract surgery. We graded the certainty of the evidence using GRADE. Two review authors independently screened the search results, assessed risk of bias and extracted data using the standard methodological procedures expected by Cochrane. The primary outcome for this review was intraoperative complications in the operated eye, namely anterior capsule and posterior capsule tears. The secondary outcomes were visual acuity (corrected distance visual acuity (CDVA) and uncorrected distance visual acuity (UDVA)), refractive outcomes, quality of vision (as measured by any validated visual function score), postoperative complications and cost-effectiveness. We included 16 RCTs conducted in Germary, Hungary, Italy, India, China and Brazil that enrolled a total of 1638 eyes of 1245 adult participants. Overall, the studies were at unclear or high risk of bias. In 11 of the studies the authors reported financial links with the manufacturer of the laser platform evaluated in their studies. Five of the studies were within-person (paired-eye) studies with one eye allocated to one procedure and the other eye allocated to the other procedure. These studies were reported ignoring the paired nature of the data.The number of anterior capsule and posterior capsule tears reported in the included studies for both laser cataract surgery and manual phacoemulsification cataract surgery were low. There were four anterior capsule tears and one posterior capsule tear in 1076 eyes reported in 10 studies (2 anterior capsule tears in laser arms, 2 anterior capsule tears and 1 posterior capsule tear in standard phacoemulsification arms). We are very uncertain as to the effect of laser-assisted surgery compared to standard phacoemulsification surgery with respect to these two outcomes. For postoperative cystoid macular oedema and elevated postoperative intraocular pressures, again the evidence was inconclusive (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.20 to 1.68; 957 eyes, 9 studies, low certainty evidence; and OR 0.57, 95% CI 0.11 to 2.86; 903 eyes, 8 studies, low certainty evidence).We found little evidence of any important difference in postoperative visual acuity between laser-assisted and standard phacoemulsification arms. There was a small advantage for laser-assisted cataract surgery at six months in CDVA. However, the mean difference (MD) was -0.03 logMAR (95% CI -0.05 to -0.00; 224 eyes, 3 studies, low certainty evidence) which is equivalent to 1.5 logMAR letters and is therefore, clinically insignificant. No studies reported patient-reported outcome measures such as visual function.There were no data reported on costs or resource use but three studies reported the time taken to do the surgery. There was little evidence of any major difference between the two procedures in this respect (MD 0.1 minutes, 95% CI -0.02 to 0.21; 274 eyes, low certainty evidence). The evidence from the 16 randomised controlled trials RCTs included in this review could not determine the equivalence or superiority of laser-assisted cataract surgery compared to standard manual phacoemulsification for our chosen outcomes due to the low to very low certainty of the evidence available from these studies. As complications occur rarely, large, adequately powered, well designed, independent RCTs comparing the safety and efficacy of laser-assisted cataract surgery with standard phacoemulsification cataract surgery are needed. Standardised reporting of complications and visual and refractive outcomes for cataract surgery would facilitate future synthesis. Data on patient-reported outcomes and cost-effectiveness are needed. Paired-eye studies should be analysed and reported appropriately.