Objectives: To investigate the efficacy of femtosecond laser-assisted cataract surgery (FLACS) with the FEMTO LDV Z8 laser system in comparison to manual conventional cataract surgery (CCS).

Background: Preservation of corneal endothelial integrity remains one of the most critical determinants of long-term visual quality after cataract surgery. The introduction of low-energy femtosecond laser systems has raised expectations for safer and more efficient procedures, particularity in cases with denser cataracts.

Methods: This is a prospective, randomized study. Here, 38 eyes in the FLACS group and 40 in the CCS group were included. The changes in central corneal thickness (CCT), endothelial cell density (ECD), and best-corrected visual acuity (BCVA) were analyzed. In addition, the effective phacoemulsification time (EPT), the total phacoemulsification time (PT), and the intraoperative time (IT) were evaluated as a function of cataract grade. The total follow-up period was six weeks. Results: On postoperative day 1, BCVA improved significantly faster in the FLACS group (0.91 ± 0.14) compared with the CCS group (0.70 ± 0.17; p < 0.05). FLACS also demonstrated a significantly shorter EPT (1.01 ± 0.91 s) than CCS (1.61 ± 1.70 s; p < 0.05). No significant differences were observed between groups regarding postoperative ECD or CCT at any time point. No intraoperative or postoperative complications occurred.

Conclusions: Low-energy FLACS achieved comparable endothelial safety to CCS, while providing significantly faster early visual recovery and reduced ultrasound energy use. These finding support the clinical value of FLACS in patients with moderate to dense cataracts.