This study group compared the higher order aberrations (HOAs) between femtosecond laser-assisted cataract surgery (FLACS) and manual cataract surgery. Consecutive patients undergoing FLACS or manual cataract surgery with implantation of an intraocular lens from January 2017 to February 2018 were recruited. Patients underwent aberrometry testing at two months postoperatively. The primary endpoint was internal coma <0.32µm, and secondary outcomes included patient-reported vision quality. Generalised estimating equations accounting for within-patient correlation were used for analysis. A total of 57 eyes underwent FLACS and 50 eyes underwent manual cataract surgery. The proportion of eyes reaching internal coma <0.32µm was significantly greater following FLACS (54 of 57 eyes, 94.7%) relative to manual cataract surgery (39 of 50 eyes, 78.0%) (odds ratio [OR] = 5.08, 95% confidence interval [CI] = 1.24 to 20.85, p=.024). The median internal coma was 0.10µm for FLACS and 0.12µm for manual cataract surgery (p=.005). There were no significant differences in vision quality between treatments (p=.40). All eyes (n=15) with satisfaction scores of 0 to 10 had internal coma <0.20µm, compared to those with scores of 11 to 20 (27 of 29 eyes, 93.1%), 21 to 30 (19 of 30 eyes, 63.3%), and >30 (eight of 15 eyes, 53.3%) (p<.001). The average internal coma increased by a greater amount for manual cataract surgery than for FLACS for every increase in mesopic pupil size >5.75 mm.
More eyes achieved internal coma <0.32µm following FLACS compared to manual cataract surgery. However, this does not account for improved patient-reported vision quality. There was a correlation between internal coma and patient-reported satisfaction, and eyes with excellent patient satisfaction all had internal coma <0.20µm. This study supports the hypothesis that FLACS produces statistically significant improvements in HOAs relative to manual cataract surgery. There are more than four times the proportion of eyes not reaching internal coma less than 0.32 microns following manual cataract surgery compared to FLACS. Further research is needed to clarify whether the same conclusions hold true in a more controlled setting.