Comparing the Efficacy and Safety of Femtosecond Laser-Enabled Keratoplasty and Conventional Penetrating Keratoplasty: A Systematic Review and Meta-Analysis

Daniyah Baqalaqil,1 Rand Sulaiman Alrayes,2 Amar Abdullah Khan,3 Ahmed Albelowi,4 Ahmed Alrehaili,5 Jumana Alasbool,6 Omniah Ahmed Almansouri,7 Rakan Hassan Alabdulali,8 Ruba M Alghanmi,1 Ziyad Alqazlan,9 Waseem A Aalam10 1College of Medicine, University of Jeddah, Jeddah, Saudi Arabia; 2Faculty of Medicine, Taibah University, Medina, Saudi Arabia; 3Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; 4Ophthalmology Department, National Guard Hospital, Medina, Saudi Arabia; 5Ophthalmology Department King Salman Bin Abdulaziz Medical City, Medina, Saudi Arabia; 6Mansoura University, Mansoura, Egypt; 7Faculty of Medicine, University of Tabuk, Tabuk, Saudi Arabia; 8Faculty of Medicine, Alfaisal University, Riyadh, Saudi Arabia; 9Department of Ophthalmology, ar Rass General Hospital, Ar Rass, Saudi Arabia; 10Department of Surgery, College of Medicine, University of Jeddah, Jeddah, Saudi ArabiaCorrespondence: Daniyah Baqalaqil, Email [email protected]: Femtosecond laser-assisted keratoplasty (FLKP) has recently emerged as an alternative to conventional penetrating keratoplasty (CPK). By enabling precise and reproducible corneal incisions, FLKP may offer improved visual outcomes and fewer complications.Methods: A systematic review was conducted using Google Scholar, PubMed, and Web of Science from inception to July 12, 2024. Included studies were nonrandomized controlled trials, retrospective cohort studies, or prospective observational cohorts comparing FLKP with CPK. Eligible studies reported at least one of the following outcomes: topographic astigmatism, visual acuity, spherical equivalent, endothelial cell density, graft rejection/failure, or complications. Non-English articles, studies comparing other keratoplasty techniques, or lacking relevant outcome data were excluded. Risk of bias was assessed using the MINORS tool. A random-effects model was used to calculate mean differences.Results: Out of 517 records, 9 studies met the inclusion criteria. FLKP was significantly superior in reducing postoperative topographic astigmatism (Z = 3.23, P = 0.001, I² = 35%) and in improving best-corrected visual acuity (BCVA) (Z = 5.03, P = 0.00001, and I2 = 4%). No significant difference was found in uncorrected visual acuity (UCVA) or spherical equivalent. FLKP also preserved endothelial cell density more effectively than CPK (Z = 2, P = 0.05, I² = 67%). While most complication rates were similar, FLKP was associated with a lower incidence of wound dehiscence.Conclusion: FLKP offers better postoperative astigmatism correction, improved BCVA, and greater endothelial cell preservation compared to CPK. It also reduces certain complications, such as wound dehiscence. However, the findings are limited by the retrospective nature and geographic focus of the included studies, underscoring the need for future long-term randomized trials.Keywords: FLKP, CPK, postoperative astigmatism, BCVA, UCVA, complications