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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 4  |  Page : 2020-2026

Corneal endothelial changes by specular microscopy after uncomplicated phacoemulsification


Department of Ophthalmology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission05-Jul-2022
Date of Decision30-Jul-2022
Date of Acceptance07-Aug-2022
Date of Web Publication04-Mar-2023

Correspondence Address:
Afaf A El Ashram
Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_226_22

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  Abstract 


Objectives
To determine the effects of phacoemulsification surgery on corneal endothelial cell density and corneal thickness in patients undergoing cataract surgery.
Background
Phacoemulsification cataract surgery with implantation of an intraocular lens is the most common procedure for cataract extraction, which may have several complications.
Patients and methods
This was a descriptive prospective study for comparative analysis of corneal endothelial changes using Tomey EM-3000 noncontact specular microscope held on selected patients with senile cataracts who attended the outpatient clinic of Menoufia Ophthalmology Center (MOC) for cataract surgery in the period from October 2021 March 2022. Cataract extraction using phacoemulsification and intraocular lens implantation was done on all patients.
Results
There was a significant reduction in mean endothelial cell density after phacoemulsification compared with baseline, with P value less than 0.001. There was also a significant postoperative reduction in mean endothelial cells number as compared with baseline, with P value less than 0.001. Mean endothelial cell hexagonality was reduced significant (P < 0.001). Central corneal thickness showed a significant increase postoperatively (P < 0.001).
Conclusion
Despite healthy cornea, no previous surgical history, and no corneal abnormalities before surgery, there was marked endothelial loss by phacoemulsification. This is particularly important in patients, especially with harder nuclear density.

Keywords: central corneal thickness, corneal endothelial, senile cataract, specular microscopy, uncomplicated phacoemulsification


How to cite this article:
El Ashram AA, Al Yamany AA, El-Ghoubashy ES, Gaber NK. Corneal endothelial changes by specular microscopy after uncomplicated phacoemulsification. Menoufia Med J 2022;35:2020-6

How to cite this URL:
El Ashram AA, Al Yamany AA, El-Ghoubashy ES, Gaber NK. Corneal endothelial changes by specular microscopy after uncomplicated phacoemulsification. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:2020-6. Available from: http://www.mmj.eg.net/text.asp?2022/35/4/2020/370985




  Introduction Top


Cataract is a major and the biggest cause of treatable blindness worldwide. It is a significantly increasing problem worldwide with a huge economic and social burden [1].

Phacoemulsification is considered nowadays the surgery of choice for cataract removal worldwide. Phacoemulsification surgery can cause corneal endothelial cell loss owing to the dissipated ultrasound energy during the procedure. Exaggeration of corneal endothelial cell loss can lead to postoperative complications such as delayed regression of corneal edema or even permanent edema of the cornea or bullous keratopathy [2].

All cataract surgical processes that contain entry into the anterior chamber harm a proportion of endothelial cells as a consequence of intraoperative corneal manipulations. After endothelial cell loss, the adjacent cells expand and slide over to sustain endothelial cell continuity, which is detected as the alteration in endothelial cell density (ECD) and morphology [3].

One of the main concerns during phacoemulsification is the effect of ultrasound energy on corneal endothelium, especially in the harder nucleus cases [4].

With modern phacosurgery, the use of more vacuum and less energy with application of torsional rather than longitudinal mode together with the advances in the field of ocular viscoelastic materials provided a less hazardous effect on various ocular structures, namely, the endothelium [5],[6],[7].

The corneal endothelium is the most posterior layer of the cornea. It is a monolayer of regularly arranged polygonal squamous cells that is uniformly distributed over the cornea. It is derived from the neural crest during embryologic development [8].

Corneal endothelial cells are non-replicative, and the loss of these cells is only compensated for by the migration, enlargement, and increasing heterogeneity of the cells [9].

Corneal endothelial cells form an anatomical and physiological barrier between the corneal stroma and the anterior chamber. They sustain an active transport of fluid at a rate of 3.5–6 μl from the stroma into the anterior chamber, thereby regulating stromal hydration [10].

Loss of endothelial function by the damage of endothelial cells can lead to increased corneal thickness and decreased corneal transparency because of increased stromal hydration due to compromised pump function [9].

ECD and function can be evaluated clinically using specular microscopy and pachymetry. Morphological constancy and functional integrity of the corneal endothelial cells are essential to sustain long-term corneal transparency after cataract surgery [11].

The proper corneal function is based on the preservation of corneal endothelial integrity, shape, and density of endothelial cells [12].

So, this descriptive prospective study was carried out to assess the corneal endothelial changes using specular microscopy, after uncomplicated phacoemulsification in moderately hard nuclear 3 senile cataracts.

The aim of the study was to determine the effects of phacoemulsification surgery on corneal ECD and corneal thickness in patients undergoing cataract surgery.


  Patients and methods Top


This was a descriptive prospective randomized study for comparative analysis of corneal endothelial changes held on selected patients with senile cataracts who attended the outpatient clinic of Menoufia Ophthalmology Center (MOC) for cataract surgery in the period from October 2021 to March 2022. Cataract extraction using phacoemulsification and intraocular lens (IOL) implantation was done on all patients.

Ethical approval and written informed consent: an approval of the study was obtained from the Menoufia University academic and ethical committee.

The certificate approval number is 12/2020 OPHT.

Every patient signed an informed written consent for the acceptance of the operation.

The inclusion criteria of this study were patient complaining of diminution of vision of gradual onset and progressive course, adult patients from 50 to 70 years of age, both sexes with no prior ocular disease, crystalline clear cornea devoid of any corneal dystrophy and degenerations, moderately hard senile cataract, undergoing routine phacoemulsification surgery, and patients with corneal ECD of more than 1500 cell/mm.

Exclusion criteria were patients with evidence of proliferative diabetic retinopathy (T2DM group) characterized by the occurrence of vitreous hemorrhage or tractional retinal detachment, local eye disease, previous surgery, preoperative endothelial count less than 1500 cells/mm, any type of corneal pathology such as corneal degeneration and corneal dystrophy, contact lens wear history, ocular trauma or surgery, current use of any kind of ocular treatment other than eye lubricant, and patients with conditions that would prevent evaluation of the cornea by specular microscopy.

Ocular examination and investigation: all the participants had a comprehensive ocular examination including visual acuity (VA) by Snellen chart including uncorrected VA and the best-corrected visual acuity (BCVA), color vision by Ichihara charts, Amsler grid to assess the macular function, and slit-lamp examination of the anterior segment. Dilation of the patient pupil was done with three drops of cyclopentolate followed by grading of the cataract according to LOCS 3. Fundus examination was done to exclude any retinal disease.

Investigations performed: corneal endothelial profile was performed using a Tomey EM-3000 noncontact specular microscope, which included ECD, hexagonality (HEX), cell number, coefficient variance of cells size (CV), and central corneal thickness (CCT) before and 1 month after phacoemulsification.

Ethical consideration: all patients received a complete explanation of the nature and the purpose of the study. Informed consent was obtained from all participants in the research before inclusion. All names of the participants were hidden and replaced by numbers to maintain the privacy and confidentiality of the data. Data were not used for any other purpose.

Postoperative care: postoperative treatment included systemic antibiotics, for example, cephradine 500 mg capsule three times/day; analgesics if needed; topical antibiotic eye drops, for example, moxifloxacin 0.5% five times/day; and steroids eye drops, for example, prednisolone acetate 1% times/day, which were tapered gradually and discontinued after 2 weeks.

Postoperative follow-up was done on the first postoperative day by complete ophthalmic evaluation, with special focus on any visual complaint, unaided VA, slit-lamp biomicroscopy to observe corneal incisions, any clinically apparent corneal edema, aqueous flare or cells, and IOL position and stability.

Frequency of follow-up: patients were examined at 1 week, 1 month, and 3 months after surgery. In each visit, the following parameters were evaluated and recorded: unaided VA, refraction and assessment of aided VA, slit-lamp biomicroscopy examination, detailed fundus examination by 90D Volk lens for examination of vitreous hemorrhage and retinal detachment, IOP, and specular microscopy using a Tomey EM-3000 noncontact specular microscope to measure endothelial cell count and CCT.

Statistical analysis

Data were collected, revised, coded, and entered into the Statistical Package for the Social Sciences, IBM SPSS, version 23 (IBM Corp., Armonk, New York, USA). The quantitative data were presented as mean, SD, and ranges when their distribution was found parametric. Moreover, qualitative variables were presented as numbers and percentages. The comparison between two independent groups with quantitative data and parametric distribution was done using an independent t test. The comparison between more than two paired groups with quantitative data and parametric distribution was done using a repeated measure analysis of variance test. Spearman correlation coefficients were used to assess the correlation between two quantitative parameters in the same group. The confidence interval was set to 95%, and the margin of error accepted was set to 5%. So, P value less than 0.05 was considered significant.


  Results Top


The mean age of the studied sample was 59.53 ± 6.334 years, ranging from 50 to 73 years. The majority of patients [20 (66.7%)] were males, whereas only 33.3% (10) were females [Table 1] and [Figure 1].
Table 1: Age and sex distribution

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Figure 1: Age distribution of the studied sample.

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[Table 2] reveals that the mean CD 1 week after phacoemulsification (2135.5 ± 416.41) was statistically significantly lower than the mean CD before phacoemulsification (2439.7 ± 377.51). The mean CD 1 month after phacoemulsification (2095.8 ± 372.33) was statistically significantly lower than the mean CD before phacoemulsification (2439.7 ± 377.51). The mean CD 3 months after phacoemulsification (2075.4 ± 282.17) was statistically significantly lower than the mean CD before phacoemulsification (2439.7 ± 377.51) [Table 2] and [Figure 2].
Table 2: Progressive changes in endothelial cell density

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Figure 2: Baseline and follow-up of CD during the current study. CD, cell density.

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[Figure 3] shows that the mean CV 1 week after phacoemulsification (44.63 ± 4.810) was statistically significantly higher than the mean CV before phacoemulsification (41.70 ± 5.234) (P < 0.001). The mean CV 1 month after phacoemulsification (43.50 ± 4.740) was statistically significantly higher than the mean CV before phacoemulsification (41.70 ± 5.234) (P = 0.030). The mean CV 3 months after phacoemulsification (43.43 ± 4.584) was statistically significantly higher than the mean CV before phacoemulsification (41.70 ± 5.234) (P = 0.035) [Table 3] and [Figure 3].
Figure 3: Baseline and follow-up of HEX during the current study. HEX, hexagonality.

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Table 3: Changes of coefficient of variation following cataract surgery

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[Figure 4] reveals that the mean HEX before phacoemulsification was 49.83 ± 2.019, ranging from 42 to 52. The mean HEX 1 week after phacoemulsification was 37.87 ± 4.462, ranging from 29 to 48. The mean HEX 1 month after phacoemulsification was 40.97 ± 5.149, ranging from 32 to 56. The mean HEX 3 months after phacoemulsification was 41.20 ± 5.034, ranging from 32 to 56. The mean change at 1 week (%) was −23.80 ± 9.936, ranging from −42 to −7. The mean change at 1 month (%) was −17.67 ± 10.463, ranging from −36 to 8. The mean change at 3 months (%) was −17.13 ± 10.458, ranging from −26 to −9.50 [Table 4] and [Figure 4].
Figure 4: Baseline and follow-up of CV during the current study. CV, coefficient variation.

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Table 4: Baseline and follow-up of hexagonality and change percent during the current study

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  Discussion Top


This descriptive prospective study was carried out to assess the corneal endothelial changes by using specular microscopy after uncomplicated phacoemulsification in moderately hard nuclear 3 senile cataract.

In our study, the mean age of the studied sample was 59.53 ± 6.334 years, ranging from 50 to 73 years.

This is in agreement with the study by Osman et al. [13], in which the age distribution range was 51–70 years, with a mean ± SD of 64.40 ± 5.47 years.

Similarly, Bourne et al.[14] found that the mean age of the patients was 56.7 years, ranging between 49 and 65 years.

Bamdad et al.[15] reported that the mean age of patients in their study was 62.1 ± 12.2 years.

This can be explained by that those who are middle aged, ∼17.5% of persons 43–54 years of age, have some evidence of lens opacity. Onset is gradual and progressive commonly in the older age group, typically in the fifth and sixth decade [16].

In our study, the majority of patients 20 (66.7%) were males, whereas only 33.3% (10) were females.

This is in agreement with the study by Osman et al. [13], where 19 (63.3%) were male and 11 (36.7%) were females.

In contrast, Bourne et al.[14] reported that 26 (52.0) of the patients were females and 24 (48.0) were males. Moreover, the studies by Bamdad et al. [15], Jagani et al. [17], Tang [18], and Zarkasi et al.[1] found that the majority of the studied patients were females.

In this study, the mean VA of the studied sample (0.09 ± 0.019) ranged from 0.05 to 0.15, and the mean refraction (−1.99 ± 3.810) ranged from – 7.00 to 4.50.

This is similar to the study by Gonzalez-Salinas et al. [19], which found that the mean value of BCVA was 0.08 ± 0.07.

Moreover, Perone et al.[20] reported that VA significantly decreased with increasing cataract severity. In this study, the mean VA of the studied sample was 0.09 ± 0.019, ranging from 0.05 to 0.15, and the mean refraction was −1.99 ± 3.810, ranged from –7.00 to 4.50.

This is similar to the study by Tanash et al. [19], which found that the mean value of BCVA was 0.08 ± 0.07. Moreover, Perone et al.[20] reported that VA significantly decreased with increasing cataract severity.

We decided to follow-up on the endothelial loss in the first week, month, and third month postoperatively, which was consistent with the studies by Gogate et al.[21] and Osman et al. [13], which followed up the endothelial loss at the same time interval postoperatively and revealed a significant decrease in endothelial cells in both the short term and long term.

Bourne et al.[14] support our study and reported stabilization of cell density throughout the cornea after phacoemulsification by 3 months. Regarding corneal changes after phacoemulsification, corneal thickness returned nearly to baseline 1 month after surgery, whereas endothelial loss persisted, being compensated by the remaining endothelial cells [15].

The majority of studies agree that phacoemulsification results in qualitative and quantitative alterations at the corneal ECD [16].

In the current study, the mean number 1 week, 1 month, and 3 months after phaco was statistically significantly lower than the mean number before phacoemulsification; however, the mean number at 3 months started to increase. Regarding cell count density, we observed a significant decrease of CD following the operation after 1 month and a much more decrease after 3 months.

Similar to our findings, Jagani et al. [17] reported a crescendo of cell loss percentage. They noticed a rate of loss of ∼12, 16, and 17% after 1, 6 weeks, and 3 months, respectively.

This is similar to the study by Bamdad et al. [15], which revealed a significant decrease in endothelial cell counts (ECC), accounting for an endothelial cell loss (ECL) value of 11.4%.

Similarly, Calvo-Maroto et al.[22] found a significant difference in both the presurgical and the postoperative follow-up visits in the percentage of cells.

In concordance with our study results, the study by Osman et al.[13] found a highly significant decrease in ECD 1 month and third month postoperatively in relation to preoperatively. It revealed a value of 16.6% loss of ECD after phacoemulsification of grade 3 hard senile cataract first month postoperatively, which increased up to 3% till the third month postoperatively.

Supporting our study results, Calvo-Maroto et al.[22] stated that there is a significant difference in the presurgical and the postoperative follow-ups in cell density.

Similarly, El Sobky et al.[7] reported that the comparison among the three studied periods (preoperatively, 1 month postoperatively, and 3 months postoperatively) cleared that the CD % differed significantly among the different studied periods.

Tang et al.[18] agreed with our study, as they found that patients have a significantly lower ECD at all postoperative time points in relation to the preoperative state. Eyes with moderately hard senile cataract were subjected to various changes owing to the cataract extraction procedure. Corneal endothelium showed morphological and morphometric alterations manifested by pleomorphism and polymegathism, as well as a lower percentage of hexagonal cells, which agrees with and supports our results.

Gonzalez-Salinas et al. [19] agreed with our results that there was a lower endothelial density by 12–14% in patients after phacoemulsification, which supports the results of our study.

On the contrary, Perone et al.[20] disagreed with us. Despite finding a similar descending pattern, they reported a lesser percentage of loss after 1 month, estimating 11%. Of note, they also depicted a 15% loss after only 4 days postoperatively.

Earlier in 2010, Gogate et al.[21] revealed a much higher percentage of cell loss following phacoemulsification, with 23 and 27% after 1 and 6 weeks postoperatively, respectively.

These findings are attributed to the resulting ECL during surgery, which affects the CD percentage and changes its level. Thus, postoperative corneal ECD can be a useful indicator of damage caused by surgical procedures. One more confounding factor for postoperative cell loss is the type of lens [23].

Moreover, it is known that ocular biometric parameters vary with sex, age, and ethnicity, and hence are different among different populations. Furthermore, studies investigate different methods of cataract surgeries, which makes the outcome inevitably different [24].

The wide range of reported endothelial cell loss in different studies can be explained through various surgical techniques, different patient populations, and time points of ECC evaluation after surgery. Several intraoperative variables including the incision type, used ophthalmic viscosurgical device (OVD), type of IOL, the composition of the irrigation solution, total phacoenergy, and location of the active phacoemulsification have been proposed as a determinant of endothelial damage [8].

Normal corneal endothelial cells have a hexagonal shape forming a regular mosaic. After insult, this morphology is disturbed (pleomorphism) and the percent of hexagonal cells is reduced [22].

Likewise, in our study, HEX slightly decreased 1 week, 1 month, and 3 months after phaco from baseline.

Although this was in line with most of the studies, such reduction varied from one study to another. Osman et al.[13] noticed a constant marked decrease in the percentage of HEX from baseline after 1 month (49–41) down to 38 after 3 months of the surgery.

Moreover, Calvo-Maroto et al.[22] stated that there was a significant difference evidenced in the presurgical and the postoperative follow-up visits in HEX.

In agreement with our study results, El Sobky et al.[7] reported that the comparison among the three studied periods (preoperatively, 1 month postoperatively, and 3 months postoperatively) cleared that HEX % differed significantly among the different periods of operations.

Similarly, the study by Gupta et al.[25] found a modest and insignificant decrease from baseline (from 41 to 37 after 1 week, to 36 after 6 weeks). The authors claim that both CV and percentage of HEX tend to return to normal after endothelial stabilization.

It is believed that the magnitude of derangement in these quantitative measurements is dependent on the presence of complications. Thus, it is logical to find some studies reporting significant differences in both measures, whereas others did not. [7] In our study, CD change, HEX change, and CCT change were found to be significantly positively correlated with SD before phacoemulsification, whereas SD change was significantly negatively correlated with it.

This is in contrast to Karekla et al.[26], who found that SD before phacoemulsification was not related to the final endothelial cell loss or final corneal edema.

In the current study, CV change was found to be significantly negatively correlated with CV before phaco.

This is in contrast to Karekla et al. [26], who found CV before phacoemulsification was not related to the final endothelial cell loss or final corneal edema.

In the current study, AVG change and SD change were found to be significantly positively correlated with CCT before phacoemulsification, whereas CCT change was significantly negatively correlated with it.

This was against Karekla et al. [26], who found CCT before phacoemulsification was not related to the final endothelial cell loss or final corneal edema.

The possible limitations of this study were the relatively small number of studied participants and the heterogeneous nature of the population regarding other coexisting medical conditions. Nonetheless, our findings add further evidence to the literature regarding the role of preoperative endothelial cells as a risk factor responsible for increased ECL following phacoemulsification.


  Conclusion Top


Despite healthy cornea, no previous surgical history, and no corneal abnormalities before surgery, there was marked endothelial loss by phacoemulsification. This is particularly important in patients, especially with harder nuclear density, so we recommend after this study the necessity to adjust the phacoemulsification parameters according to pentagram nucleus staging to reach the least endothelial cell loss and refine the current surgical methods and instruments to minimize the endothelial damage. This descriptive prospective study was carried out to assess the corneal endothelial changes by using specular microscopy after uncomplicated phacoemulsification in moderately hard nuclear 3 senile cataract.

Authors' contributions

All authors contributed to this project and article equally. All authors have read and approved the final manuscript.

Acknowledgements

The authors are grateful to the staff of the Department of Ophthalmic Medical Photography of Menoufia Eye Hospital for helping in the data collection process.

Financial support and sponsorship

The study was supported by a research grant of Menoufia University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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