Femtosecond Laser Arcuate Keratotomy vs Toric Intraocular Lens Implantation in Cataract Surgery

Importance: After cataract surgery, postoperative residual astigmatism can influence a patient's visual quality and satisfaction. Finding ways to minimize this astigmatism is important. Objective: To compare the clinical outcomes of femtosecond laser arcuate keratotomy (FSAK) and toric intraocular lens (TIOL) implantation for astigmatism correction in patients undergoing femtosecond laser-assisted cataract surgery. Design, Setting, and Participants: This randomized clinical trial was conducted between October 2021 and September 2023 at the Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, China. Patients with mild to moderate regular corneal astigmatism ranging from 0.75 diopters (D) to 3.00 D were recruited. Interventions: Patients were randomly assigned in a 1:1 ratio to receive FSAK or TIOL implantation. Main Outcomes and Measures: The primary outcome was the subjective manifest refraction assessed at 3 months postoperatively. Results: A total of 196 patients (mean [SD] age, 68.4 [13.7] years; 124 female [63%]) were randomized to the FSAK group (98 [50%]) or TIOL group (98 [50%]), and 92 patients (94%) and 95 patients (97%), respectively, finished the 3-month follow-up. At 3 months postoperatively, there was no difference in the refractive astigmatism between the 2 groups (mean [SD], 0.64 [0.64] D vs 0.54 [0.55] D; difference, 0.11 D; 95% CI, -0.06 to 0.27 D; P = .21). The mean (SD) uncorrected distance visual acuity was 0.15 (0.20) logMAR (Snellen equivalent, 20/28) for the FSAK group and 0.14 (0.19) logMAR (Snellen equivalent, 20/28) for the TIOL group (difference, 0.01 D; 95% CI, -0.04 to 0.06 D; P = .71). Subgroup analyses showed that TIOL implantation achieved lower residual astigmatism compared with FSAK when treating astigmatism exceeding 1.5 D or against-the-rule astigmatism. Conclusions and Relevance: Results of this randomized clinical trial demonstrate that in study participants with mild to moderate astigmatism undergoing femtosecond laser-assisted cataract surgery, FSAK was not superior to TIOL implantation for astigmatism correction. However, for astigmatism exceeding 1.5 D or against-the-rule astigmatism, TIOL implantation demonstrated greater efficacy over FSAK. Future trials are needed to determine if there is greater efficacy of TIOL implantation over FSAK as suggested by subgroup analyses. Trial Registration: ChiCTR.org.cn Identifier: ChiCTR2100051066.