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Femtosecond laser-assisted astigmatic keratotomy versus toric IOL implantation for correcting astigmatism in cataract patients: a systematic review and meta-analysis with trial sequential analysis
  1. Wei-Ting Yen1,2,
  2. Tzu-Heng Weng1,2,
  3. Ting-Yi Lin1,2,
  4. Ming-Cheng Tai1,2,
  5. Yi-Hao Chen1,2,
  6. Yu-Min Chang1,2
  1. 1Department of Ophthalmology, Tri-Service General Hospital, Taipei City, Taiwan
  2. 2National Defense Medical Center, Taipei City, Taiwan
  1. Correspondence to Dr Yu-Min Chang, Department of Ophthalmology, Tri-Service General Hospital, Taipei City 11490, Taiwan; m7886916{at}


Aims To compare the refractive and visual outcomes of femtosecond laser-assisted astigmatic keratotomy (FSAK) and toric intraocular lens (IOL) implantation for correcting astigmatism in cataract patients.

Methods Studies were retrieved from the Ovid-Medline, EMBASE, Cochrane Central Register of Controlled Trials and Scopus which compared FSAK and toric IOL for astigmatism correction in cataract patients. Outcome measures included postoperative refractive cylinder, correction index, uncorrected distance visual acuity (UDVA), the proportion of patients achieving a residual refractive cylinder of 1.00 dioptre or less, target-induced astigmatism (TIA) and surgically induced astigmatism (SIA). The trial sequential analysis (TSA) was used to collect firm evidence supporting our conclusion.

Results 9 studies encompassing 590 participants were analysed. The meta-analysis revealed that toric IOLs could result in less postoperative refractive cylinder and provide better UDVA compared with FSAK. The TSA disclosed strong evidence of lower postoperative refractive cylinder in the toric IOL group compared with that of the FSAK group. FSAK showed a smaller correction index and lower mean TIA and SIA compared with toric IOLs.

Conclusions For cataract patients, both FSAK and toric IOLs are effective methods for correcting astigmatism. However, toric IOLs offer less postoperative astigmatism and result in better postoperative UDVA compared with FSAK. In vector analysis of astigmatism, toric IOLs can also produce higher TIA and SIA. Additionally, neither method is associated with severe untreatable complications. Therefore, the conclusion is that toric IOLs are the preferred choice for astigmatism correction in cataract patients and FSAK serves as a viable alternative when toric IOLs are contraindicated.

  • Ophthalmologic Surgical Procedures
  • Cornea
  • Optics and Refraction
  • Treatment Lasers

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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  • Contributors Y-MC was the guarantor of the study. W-TY and Y-MC conceived and designed the study. W-TY, T-HW and Y-MC contributed to database search, data extraction and quality assessment. W-TY and Y-MC performed the meta-analysis and wrote the first draft of the study. W-TY, T-YL, M-CT, Y-HC and Y-MC contributed to the interpretation of data analysis and critical revision of the manuscript. Y-MC supervised the whole study process. All authors contributed to and approved the final manuscript. All authors met the ICMJE criteria for authorship.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.