Corneal endothelial cell loss after trabeculectomy and phacoemulsification in one or two steps: a prospective study

María Isabel Soro-Martínez,Miriam Pastor-Montoro,Juan Antonio Miralles De Imperial-Ollero,María Paz Villegas-Pérez,Gabriel Arcos-Villegas,Jaime Miralles De Imperial-Mora-Figueroa,José María Ruiz-Gómez,Paloma Sobrado-Calvo

doi:10.1038/s41433-020-01331-x

Abstract

ObjectiveThe objective of this study was to analyse the results of the surgical treatment of coexisting cataract and glaucoma and its effects on corneal endothelial cell density (CECD).MethodsWe include two longitudinal prospective studies: one randomised that included 40 eyes with open angle glaucoma that received one- (n = 20) or two-step (n = 20) phacotrabeculectomy and another that included 20 eyes that received phacoemulsification. We assess the impact of surgery on different clinical variables and in particular in CECD using Confoscan 4™ confocal microscopy and semiautomatic counting methods.ResultsPhacoemulsification and phacotrabeculectomy, but not trabeculectomy, increase significantly best-corrected visual acuity and anterior chamber depth and trabeculectomy and one- or two-step phacotrabeculectomy decreased similarly the intraocular pressure. We document percentages of endothelial cell loss of 3.1%, 17.9%, 31.6% and 42.6% after trabeculectomy, phacoemulsification and one- or two-step phacotrabeculectomy, respectively. The coefficient of variation did not increase significantly after surgery but the percentage of hexagonality decreased significantly after phacoemulsification and after two-step phacotrabeculectomy.ConclusionsTrabeculectomy, phacoemulsification and phacotrabeculectomy are surgical techniques that cause morphological changes and decrease the densities of the corneal endothelial cells. Trabeculectomy produces lesser endothelial cell loss than phacoemulsification, and phacoemulsification lesser cell loss than phacotrabeculectomy. Two-step phacotrabeculectomy (trabeculectomy followed 3 months later by phacoemulsification) causes more cell loss than one-step phacotrabeculectomy, and this could be due to the cumulative effects of two separate surgical traumas or to a negative conditioning lesion effect of the first surgery. For the treatment of coexisting glaucoma and cataract, one-step phacotrabeculectomy is the treatment of choice.

Highlights

Corneal transparency is critical for vision and depends largely on the function of the corneal endothelial cells
We present the findings of two different prospective studies in which we have analysed Corneal endothelial cell density (CECD) after one- or two-step phacotrabeculectomy and after phacoemulsification
There were no significant differences in Central corneal thickness

Summary

Introduction

Corneal transparency is critical for vision and depends largely on the function of the corneal endothelial cells. These cells have a regular hexagonal form in children, but with age they show an increase in size (polymegathism) and a decrease of their regular hexagonal morphology (pleomorphism) [1,2,3]. Corneal endothelial cell density (CECD) is normally between 2600 and 2900 cells/mm in adults [3,4,5] and decreases in corneal diseases or after anterior segment surgery. When CECD is below 400–700 cells/mm, there is corneal oedema and vision loss. The most common aetiology of corneal oedema is cataract surgery [6]. Filtering glaucoma surgery causes less cell loss than cataract surgery [7,8,9,10,11,12,13,14,15,16], but it may

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