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Original Article
Comparison of Morphological and Functional
Endothelial Cell Changes after Cataract Surgery:
Phacoemulsification Versus Manual SmallIncision
Cataract Surgery
Sunil Ganekal1,2, Ashwini Nagarajappa2

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ABSTRACT
Purpose: To compare the morphological(cell density, coefficient of variation and
standard deviation) and functional(central corneal thickness) endothelial changes after
phacoemulsification versus manual smallincision cataract surgery(MSICS).
Design: Prospective randomized control study.
Materials and Methods: In this prospective randomized control study, patients were randomly
allocated to undergo phacoemulsification(Group1, n=100) or MSICS(Group2, n=100)
using a random number Table. The patients underwent complete ophthalmic evaluation
and specular microscopy preoperatively and at 1and 6 weeks postoperatively. Functional
and morphological endothelial evaluation was Noncon ROBO PACHY SP9000 specular
microscope. Phacoemulsification was performed, the chop technique and MSICS, by the
viscoexpression technique.
Results: The mean difference in central corneal thickness at baseline and 1week between
Group1 and Group2 was statistically significant(P=0.027). However, this difference at baseline
when compared to 6week and 1week, 6weeks was not statistically significant(P>0.05).
The difference in mean endothelial cell density between groups at 1week and 6weeks was
statistically significant (P = 0.016). The mean coefficient of variation and mean standard
deviation between groups were not statistically significant(P>0.05, both comparisons).
Conclusion: The central corneal thickness, coefficient of variation, and standard deviation
were maintained in both groups indicating that the function and morphology of endothelial
cells was not affected despite an initial reduction in endothelial cell number in MSICS. Thus,
MSICS remains a safe option in the developing world.

Website:
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DOI:
10.4103/0974-9233.124098
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Key words: Cataract Surgery, Endothelial Cell Changes, Endothelail Changes, Specular
Microscopy

INTRODUCTION

he mean endothelial count(ECC) in the normal adult

cornea ranges from 2000 to 2500cells/mm2, and the count
continues to decrease with age. Previous crosssectional studies
have shown the normal attrition rate of corneal endothelial

cells is 0.3-0.5% per year.1,2 Morphological stability and

functional integrity of the corneal endothelium are necessary
to maintain longterm corneal transparency after cataract
surgery. Endothelial cell loss and corneal decompensation after
cataract surgery is welldocumented. All surgical procedures that
involve entry into the anterior chamber damage a proportion

Nayana Superspecialty Eye Hospital and Research center, 2Department of Ophthalmology, Jayadeva Jagadguru Murugarajendra
Medical college, Davangere, Karnataka, India
1

Corresponding Author: Dr.Sunil Ganekal, Nayana Super Specialty Eye Hospital and Research Center, Davangere, Karnataka, India.
Email:drgsunil@yahoo.com

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Ganekal and Nagarajappa: Morphological and Functional Corneal Endothelial Changes after Cataract Surgery

of endothelial cells intraoperative corneal manipulation. After

endothelial cell loss, the adjacent cells enlarge and slide over
to maintain endothelial cell continuity, which is observed as a
change in the endothelial cell density and morphology. Moderate
damage to the endothelium during surgery can also lead to a
transient increase in corneal thickness. Endothelial cell density
and function can be assessed clinically using specular microscopy
and pachymetry.
Studies, normal population to assess the response of the
endothelium to cataract surgery, have shown a decrease in the
endothelial density over a 3month period postoperatively,
with an increase in the coefficient of variation and decrease in
the percentage of hexagonal cells.3,4 Previous studies reported
no significant difference in endothelial cell loss among the
conventional extracapsular cataract extraction(ECCE), manual
smallincision cataract surgery(MSICS) and phacoemulsification
groups.5
In developing countries such as India, where there is a cataract
backlog, MSICS with intraocular lens(IOL) implantation
promises to be a viable costeffective alternative to
phacoemulsification.6 In India, approximately 5 million cataract
surgeries are performed per year; therefore, it is important to
determine the safest surgical technique for the endothelium.
There is a paucity of data from India on the effect of smallincision
cataract surgery(SICS) and phacoemulsification on the corneal
endothelium(morphological and functional) was performed
to assess the postoperative endothelial cell loss and change in
endothelial morphology over a short period of time between the
two commonly performed cataract techniques.

a preoperative endothelial cell count of less than

2000cells/mm2, intraoperative conversion of surgical technique
from phacoemulsification to MSICS, intraoperative posterior
capsular rupture with vitreous loss or those unable or unwilling to
provide informed consent were excluded from the study. All the
surgeries were performed by one surgeon(SG). The surgeon was
masked to the technique until just prior to surgery. Optometrists
and ophthalmologists examining the patient postoperatively were
not masked to the type of surgery. Randomization was performed
to minimize confounding, especially that which would result if
the hardness of cataract and preoperative visual acuity were used
to assign the type of surgery. Patients were randomly allocated
using a randomization Table. The sample size estimation was
based on an 80% power to detect a 20% difference in endothelial
cell loss at a 5% level of significance and with a 20% loss to
followup. The sample size meeting this requirement was 100 for
each surgical technique(i.e.,phacoemulsification and MSICS).
All patients underwent complete ophthalmic examination and
biometry followed by measurement of central corneal thickness,
specular microscopy(endothelial images) was performed at
baseline(preoperative) and postoperatively at 1 and 6weeks.
All the parameters were tabulated.
Surgical technique

Study patients included 200 consecutive patients who were

agematched and had similar lenticular changes based on
lens opacities classification system III). All patients had a
minimum followup of 6weeks. The duration of study was
from January 2011 to October 2011. The consecutive patients
were divided into two groups, Group1(n=100, underwent
phacoemulsification), Group2(n=100, underwent MSICS).
Both cataract surgery techniques met the accepted standards
worldwide and had been used in many parts of the world for
over a decade. All walkin patients to the hospital with operable
cataract were asked to participate. The study was approved by
the local ethics committee and written informed consent was
obtained from all subjects prior to participation. Some of the
consents were in local language to ensure validity. Patients were
free to withdraw from the study at anytime and were assured that
the study would not compromise the quality of their eye care.

MSICS
After a subtenons block of 56 cc of lidocaine hydrochloride
2% with (1:20000) adrenaline, the surgical area was cleansed
and draped and the lids were separated using a wire speculum.
Afornixbased conjunctival flap was made at the temporal
limbus, and bleeding was cauterized with ballpoint cautery
as required. A6.0mm incision was made on the sclera
1.5mm from the temporal limbus. Atunnel was created with
a stainless steel crescent knife. Aside port was made at 12
or 6 Oclock. Hydroxypropyl methylcellulose(HPMC) 2%
was injected to fill the anterior chamber. A26gauge bent
capsulotomy needle/forceps was used to create a continuous
curvilinear capsulorhexis(CCC). An entry was made through the
tunnel using a 3.2mm keratome. The tunnel was then extended
using an extension blade. Hydrodissection was performed
using balanced salt solution. The anterior chamber was refilled
with viscoelastic(HPMC 2%) and the nucleus rotated and
tumbled into the anterior chamber with a Sinskey hook. The
viscoelastic was again injected below as well as above the nucleus
to protect the endothelium. The nucleus was then delivered by
viscoexpression. The remaining cortical matter was removed
with an irrigation/aspiration(I/A) cannula. After which a
polymethylmethacrylate posterior chamber IOL was implanted
in the capsular bag under saline infusion from the side port. Just
prior to the end of surgery, a subconjunctival injection(0.3mL,
10mg gentamicin and 2mg dexamethasone) was performed.

Subjects with active eye disease, history of serious eye injury,

prior eye surgeries, diabetes, another cause of decreased
vision(e.g.,glaucoma or retinal pathology, pseudoexfoliation),

Phacoemulsification Phaco machine was used for all the cases

and all the cases were performed by one surgeon(SG). Under
topical anesthesia with, 3.0mm clear corneal temporal incision

MATERIALS AND METHODS

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Ganekal and Nagarajappa: Morphological and Functional Corneal Endothelial Changes after Cataract Surgery

was made on the steeper meridian with a blade. Two side ports
were made at 12 Oclock and 6 Oclock. Sodium hyaluronate
1% was injected through a side port. ACCC was made with a
26gauge bent capsulotomy needle/forceps. Hydrodissection and
hydrodelineation were performed using balanced salt solution.
The viscoelastic was then injected and the nucleus stabilized with
the chopper. The nucleus was fragmented and removed by direct
chop technique. The rest of the cortical matter was removed
using an I/A handpiece. Afoldable posterior chamber IOL was
inserted in the capsular bag with a lens injector under saline
infusion from the side port. Asubconjunctival injection(0.3mL)
of 10mg gentamicin and 2mg dexamethasone was. The eye
was not patched since surgery was performed topical anesthesia.
Postoperatively, a combination of antibiotic and steroid eye drops
was used in both the groups for similar duration and taper along
with cycloplegic eye drops.
Specular microscopy and image analysis

The NonCon Robo Pachy Model SP9000 specular microscope

was used to record two central corneal endothelial images.
Endothelial image analysis was performed with the KSS300S
image analysis system. The endothelial image from each subject
with the greatest number of discernible cells was selected
[Figure1]. The button on the main menu was chosen,
prompting an analysis screen to appear. Left click of the mouse
allowed to manually place a green dot at the center of each cell.
Dots were placed in as many contiguous cells as possible and
no cells were omitted in the middle of the group. After all the
dots were placed, the End button was selected, and the main
screen appeared with the results of the analysis, including cell
density, coefficient of variation, and the percentage of hexagonal
cells. Mean and standard deviation of baseline parameters were
calculated for age, type of cataract, and endothelial microscopy
parameters. Comparison of mean changes in the central corneal
thickness, cell density, coefficient of variation, and standard
deviation both within and between groups at 1week and 6weeks

as compared to baseline. Comparisons were performed analysis

of variance, with 95% level of significance, P<0.05. Data were
entered, an excel file format and subsequently analyzed with
SPSS (Statistical Package for Social Sciences) version17(IBM
Corp., NewYork, NY, USA).

RESULTS
There were 100patients who underwent phacoemulsification
(Group1) and 100patients who underwent MSICS(Group2).
The mean age of Group1 was 59.48years[95% confidence
interval (CI): 54.8164.15years) and 58.48years(95% CI;
55.4361.53years) for Group2. There were 110(55%) males.
There was no statistically significant difference in demographic
variables(e.g.,age, sex) between groups.
Comparison of the mean values of central corneal thickness
between groups preoperatively and postoperatively at 1 and
6weeks is presented in Table1. At 1week postoperatively, the
mean increase in corneal thickness was 9.44m in Group1
and 10.48m in Group2. At 6weeks postoperatively, the
mean corneal thickness was decreased by 3.44m in Group1
and increased by 1m in Group2. The mean difference in
central corneal thickness at baseline and 1week between
Group1 and Group2 was statistically significant(P=0.027).
However, this difference at baseline with 6week and 1week
with 6weeks was not statistically significant(P>0.05, all
comparisons).
Comparison of the mean cell density between groups
preoperatively and postoperatively at 1 and 6weeks is
presented in Table2. The mean endothelial cell density was
2247.80353.80 cell/mm2(95% CI: 2101.76-2393.84).
2018.88290.45 cell/mm2(95% CI: 1898.99-2138.77).
There was a decrease in cell density of 76.12cells/mm2(3.27%)
in Group1 and 315.08cells/mm2(13.49%) in Group2. This
difference in mean endothelial cell density at 1week and 6weeks
was statistically significant.
Comparison of the mean values of the coefficient of variation
between groups at preoperatively and postoperatively at
1week and 6weeks is presented in Table3. The difference in
mean coefficient of variation between groups was statistically
significant.

DISCUSSION

Figure1: Endothelial cell analysis

58

Manual smallincision techniques are gaining popularity as

quick, relatively inexpensive techniques for largescale cataract
management in the developing world. Phacoemulsification has
been shown to be safe for the corneal endothelium.5,7,8 However,
postoperative visual acuity and complication rates are the same
phacoemulsification and SICS.9
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Ganekal and Nagarajappa: Morphological and Functional Corneal Endothelial Changes after Cataract Surgery
Table1: Comparison of the mean values(standard deviation) of central corneal thickness between the two groups at preoperative and
postoperatively at 1 and 6weeks
CCT (n=200)
(group)
1(n=100)
2(n=100)

P value

MeanSD
Baseline

1week

6weeks

*Baseline to 1week

Baseline with 6weeks

1week to 6weeks

578.0423.96
559.7632.05

587.4822.16
570.2440.63

574.6021.29
560.7633.68

0.027*

0.069

0.089

n: Total number of patients in each group, CCT: Central corneal thickness, SD: Standard deviation; *P<0.05

Table2: Comparison of the mean values of cell density between the two groups at preoperative and postoperatively at 1 and 6weeks
CD (n=200)
(group)
1(n=100)
2(n=100)

P value

MeanSD
Baseline

1week

6weeks

*Baseline to 1week

Baseline with 6weeks

1week to 6weeks

2323.92344.82
2333.963286.7

2175.72393.12
1994.28294.49

2247.80353.80
2018.88290.45

0.917

0.071

0.016*

n: Total number of patients in each group, CD: Cell density, SD: Standard deviation; *P<0.05

Table3: Comparison of the mean values of coefficient of variation between the two groups at preoperative and postoperatively at
1and 6weeks
CV (n=200)
(group)
1(n=100)
2(n=100)

P value

MeanSD
Baseline

1week

6weeks

*Baseline to 1week

Baseline with 6weeks

1week to 6weeks

38.526.93
42.526.28

41.247.65)
45.848.57

42.368.08
42.6013.97

0.063

0.051

0.941

n: Total number of patients in each group. CV: Coefficient of variation, SD: Standard deviation; *P<0.05

Endothelial alteration is considered an important parameter

of surgical trauma and essential for estimating the safety of
the surgical technique. After cataract surgery, endothelial cell
density decreases at a greater rate than in healthy, unoperated
corneas. There is a wide variation in endothelial cell loss
between the various studies even when the mode of surgery
is same(e.g.,SICS). This is due to various factors including,
different inclusion and exclusion criteria, different grades
of cataract, different methods of nucleus delivery in SICS,
different types of irrigating solution and viscoelastics. The
reported endothelial loss varies between 4% and 25%, and
the period of increased postoperative endothelial cell loss
remains unknown.10 Endothelial cell loss begins soon after
surgery, continues for at least 10years postoperatively and may
throughout the patients life.
A study comparing phacoemulsification and conventional ECCE6
reported a 10% reduction in endothelial cells in both groups.
In a study comparing endothelial cell loss after conventional
ECCE, MSICS, and phacoemulsification,5 the ECC decreased
by 4.72%, 4.21%, and 5.41%, respectively, with no significant
difference between the three groups. Another study7 evaluated
endothelial cell damage after phacoemulsification and planned
ECCE with different capsulotomy techniques. The mean cell
loss was 11.8% in the phacoemulsification group, 12.8% in the
ECCE group that underwent CCC and 10.1% in the ECCE
group that underwent letterbox capsulotomy. The occurrence
of posterior capsular rupture and vitreous loss at surgery
leads to a statistically significantly higher endothelial cell loss
(18.9% vs. 11.5%; P=0.003).5 However, this factor did not

affect the results of the current study as we excluded all cases

with capsular rupture.
In our study, over6weeks there was decrease in cell density
of 76.12cells/mm2(3.27%) for phacoemulsification and
315.08 cells/mm2 (13.49%) for MSICS. This difference in mean
endothelial cell density at 1week and 6weeks was statistically
significant(P=0.016). This depicts that in Group1 the mean
endothelial cell density at 1 and 6weeks stabilized and was
maintained, whereas the cell density in the MSICS at 1 and 6weeks
was reduced significantly. The SICS technique carries greater risk of
endothelial loss that is mainly attributed to surgical manipulation in
the anterior chamber close to corneal endothelium and endothelial
trauma during the nucleus delivery from the anterior chamber.
The manipulation during nucleus delivery further increases by
the temporal scleral tunnel approach used in this study(scleral
tunnel approach was performed to reduce the postoperative
astigmatism). Various modifications of SICS(irrigating vectis,
viscoexpression of the nucleus, anterior chamber maintainer, high
density viscoelastics) have significantly reduced the endothelial cell
loss. In phacoemulsification, the maneuvering is mechanical and
performed in the capsular bag, distantly from the endothelium
and newer advanced phacoemulsification units with better fluidics
may reduce the chances of endothelial damage.
One of the limitations of this study was that only 1 technique of
phacoemulsification and one technique of SICS were compared;
other techniques may give different results. In addition, stainless steel
blades instead of diamond knives were used for phacoemulsification
and sodium hyaluronate 1.4%(Healon GV) was not used in

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Ganekal and Nagarajappa: Morphological and Functional Corneal Endothelial Changes after Cataract Surgery

order to reduce the cost of the surgery. Aviscoelastic with higher

retention may have resulted in less endothelial cell loss. An Indian
study has shown that safety to the endothelium was similar with
the use of sodium hyaluronate for phacoemulsification and HPMC
for MSICS.11 Another study from Italy has show no significant
decrease in mean endothelial cell density with the use of four
different viscoelastics(HPMC, Healon, Healon GV, and Viscoat).
Hence we opted for HPMC in MSICS.12
A study from Italy13 compared endothelial cell damage between
scleral tunnel incisions and clear corneal tunnel. Contrary to our
study, t13 concluded that scleral tunnels led to less postoperative
endothelial cell damage than clear corneal tunnels. Because
MSICS was performed through the scleral tunnel incision, it may
have caused less endothelial cell loss than phacoemulsification
performed through a clear corneal tunnel incision.
Another major weakness of our study was the shortterm
followup (6weeks). However, a prospective study from United
States evaluating the longterm safety(5years) of phakic found
that the rate of endothelial cell loss decreases over time.14 This
agrees with short term studies,15 which report a higher rate of
endothelial cell loss than longer studies but decrease with time.
Endothelial cell loss is more likely related to corneal endothelial
cell remodeling after the trauma of surgery than to ongoing
agerelated cell loss.16 A study comparing the effect of different
phacoemulsification techniques on corneal endothelial cells
found similar outcomes at 3months and 1year, postoperatively.15
Based on this outcome, we believe that shortterm followup is
adequate to predict the longterm outcomes. Additionally, we
used 6weeks followup to reduce the number of patients lost
to followup, which increase the validity of the present study.
Even though postoperatively, there was statistical significant
decrease in the cell density loss in MSICS compared to
phacoemulsification over a shortterm followup of 6weeks.
However, the central corneal thickness, coefficient of variation,
and standard deviation were maintained in both groups indicating
that the function and morphology of endothelial cells, was not
affected despite a reduction in cell number in MSICS compared
to phacoemulsification. Thus, there was no difference in safety
between MSICS and phacoemulsification. MSICS is still a safe
and costeffective option in the developing world. Proper case
selection, diligent surgery, and adequate postoperative care are
essential to maintain a clear cornea.

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Cite this article as: Ganekal S, Nagarajappa A. Comparison of

morphological and functional endothelial cell changes after cataract surgery:
Phacoemulsification versus manual small-incision cataract surgery. Middle
East Afr J Ophthalmol 2014;21:56-60.
Source of Support: Nil, Conflict of Interest: None declared.

Middle East African Journal of Ophthalmology, Volume 21, Number 1, January - March 2014