Cataracts: Comparison of femtosecond laser-assisted surgery with standard surgery

In the “ThemenCheck Medizin” procedure offered by the German Institute for Quality and Efficiency in Health Care (IQWiG), interested members of the public can submit proposals for the assessment of medical procedures and technologies. On behalf of IQWiG, an interdisciplinary team of researchers led by the Medical University of Graz and “Gesundheit Österreich GmbH“, Vienna, Austria, analysed the advantages and disadvantages of two surgical techniques for cataracts. Femtosecond laser-assisted cataract surgery was compared with standard cataract surgery in adults.

The researchers analysed the results of 35 studies in which about 7200 eyes of 5510 patients were treated with one of the two surgical techniques. These studies show no advantages or disadvantages of laser-assisted surgery over the standard procedure - both procedures are safe and effective.

A question from a member of the public was the starting point for the ThemenCheck report

Cataracts are an eye disease that usually develops in people over the age of 50 and affects about 50 per cent of people over the age of 74. One or both lenses of the eye become cloudy, causing vision to deteriorate and become increasingly blurred and hazy. The only effective treatment option is surgery to replace the cloudy lens with a new artificial lens. Cataract surgery is one of the most common operations performed in Germany - it is estimated that between 700,000 and 900,000 operations are performed each year. Cataract surgery usually involves making small incisions in the cornea and lens capsule with a scalpel, using ultrasound to shred the cloudy lens, and then removing it by suction. The eye surgeon then inserts an artificial lens in its place.

The member of the public who proposed the topic said that some doctors offer laser-assisted surgery as an alternative, where the small incisions in the cornea and the shredding of the lens are done with a femtosecond laser rather than a scalpel or ultrasound. This should make the operation more precise and less invasive. He asked whether the laser-assisted procedure had any advantages over other surgical procedures.

Against this background, IQWiG commissioned the external researchers to investigate whether laser-assisted surgery can bring benefits to patients, such as better distance vision, fewer complications during or after surgery, or an improvement in vision-related quality of life.

Both procedures are safe and effective - the femtosecond laser offers no additional advantages or disadvantages for patients

The experts analysed a total of 35 studies in which 7189 eyes of 5510 patients were treated with one of the two surgical techniques. The main outcomes analysed in these randomized controlled trials (RCTs) were vision, achievement of the desired vision after surgery, and complications during or after surgery.

The research team summarized the results of the assessment as follows: The studies showed no advantages or disadvantages of laser-assisted surgery compared with standard surgery. Rather, both procedures are safe and similarly effective. Most people’s vision returned to normal 1 to 12 months after surgery, regardless which procedure was used. Quality of life also improved with both procedures. There were also no differences in terms of safety: complications such as inflammation, swelling or damage to the lens capsule were rare with both procedures.

The cost of standard surgery is around €900 to €1000 per eye and is fully covered by statutory health insurance (SHI). The cost of laser surgery is around €700 to €2100. In addition, there are usually material costs, for example for disposable materials that are used during the operation. Laser surgery is usually not fully covered by SHI; patients in Germany must pay the difference out of their own pocket.

When deciding on the type of procedure for cataract surgery, it is important to provide patients with objective advice and information so that they can make an informed choice. This is all the more important given the cost to patients who opt for laser-assisted surgery.

The “ThemenCheck Medizin” procedure

In a two-stage selection process, which also involves members of the public, up to five new topics are selected each year from all the proposals submitted. According to the legal mandate, these should be topics of particular importance for patient care. The ThemenCheck reports are not written by IQWiG itself, but by external experts. Their assessment is published together with an easy-to-understand summary and a publisher’s comment by IQWiG.

The Institute published the preliminary results of the report "Cataracts: Does femtosecond laser-assisted surgery offer advantages to patients over other procedures?" in January 2024 as a preliminary ThemenCheck report and invited comments. After the end of the commenting procedure, the report was revised and published in its final version in July 2024. An English translation was published in June 2025.