Efficacy and safety of five femtosecond laser platforms in cataract surgery: a network meta-analysis informing platform-specific clinical decision-making

Background To compare the efficacy and safety of five femtosecond laser platforms (FLPs) in femtosecond laser-assisted cataract surgery (FLACS) and guide clinical selection. Methods Systematic searches (PubMed, Cochrane Library, Web of Science, Embase, ClinicalTrials.gov, Chinese databases) identified randomized controlled trials and cohort studies (from January 2009 to May 2024) on FLACS for age-related cataracts. Outcomes included cumulative dissipated energy (CDE), effective phacoemulsification time (EPT), uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), corneal endothelial density (CED), central corneal thickness (CCT), overall complications (OCs), capsular complications (CapCs), corneal complications (CorCs), and conjunctival complications (ConCs). Continuous outcomes were expressed as weighted mean differences (WMDs) with 95% confidence intervals (CIs), while dichotomous outcomes were reported as odds ratios (ORs) with 95% CIs. The study protocol has been registered on INPLASY PROTOCOL (INPLASY202480118). Results Fifteen studies (1,570 eyes) were included. All five FLPs significantly reduced CDE compared with PCS (all P < 0.05), with LDV Z8 achieving the lowest CDE. All five FLPs also significantly shortened EPT (all P < 0.05), with LensAR showing the greatest reduction and LDV Z8 the least (SUCRA ranking: LensAR > Catalys > LenSx > LDV Z8 > PCS). LenSx showed superior UDVA and CDVA compared with PCS and LensAR (all P < 0.05). Among all FLPs, Victus showed the lowest CED and the largest CCT increase, indicating the greatest corneal endothelial damage (all P < 0.05). Catalys had the lowest OCs, CapCs, and ConCs. LenSx had the lowest CorCs, while LDV Z8 had the highest. Conclusions FLACS demonstrates consistent advantages over PCS. Platform-specific strengths include Catalys for endothelial protection and complication reduction, LenSx for visual outcomes and corneal safety, LensAR for corneal stability, and LDV Z8 for energy efficiency. These findings provide preliminary evidence to inform platform selection, but the limited direct data—especially for newer platforms—warrant caution.