Comparative Evaluation of Corneal Endothelial Changes after Phacoemulsification versus Manual Small-Incision Cataract Surgery in Grade-4 Nuclear Cataracts: A Randomised Observational Study

Abstract

Purpose: To compare postoperative corneal endothelial morphology and visual outcomes after phacoemulsification (PHACO) and manual small-incision cataract surgery (SICS) in eyes with grade-4 nuclear cataract. Methods: In this single-centre, randomised observational study, 90 eyes of 90 patients were allocated to PHACO (n = 45) or SICS (n = 45). Pre-operative and postoperative (1 week, 6 weeks, 3 months) assessments included endothelial cell density (ECD), coefficient of variation (CV), hexagonality (%Hex), central corneal thickness (CCT), uncorrected (UCVA) and best-corrected visual acuity (BCVA) using specular microscopy and logMAR charts. Primary outcome was percentage ECD loss at 3 months. Secondary outcomes were changes in CCT, CV, %Hex, and visual acuity. Results: Baseline characteristics were comparable between groups (mean age 54.0 ± 4.7 y vs 56.0 ± 3.9 y; p = 0.07). Mean ECD loss at 3 months was 13.6 ± 2.5 % (PHACO) versus 13.0 ± 1.5 % (SICS) (p = 0.16). CCT increased transiently at week 1 (PHACO +42 µm; SICS +22 µm) before returning to near-baseline by month 3 (p > 0.05 for all inter-group comparisons). CV and %Hex changed similarly in both groups, indicating comparable endothelial remodelling. Median BCVA improved from 0.64 to 0.06 logMAR (PHACO) and 0.71 to 0.09 logMAR (SICS) at 3 months (p = 0.39). No sight-threatening complications occurred. Conclusions: PHACO and SICS yield equivalent endothelial preservation and visual rehabilitation in dense nuclear cataracts when performed by an experienced surgeon. Given its lower cost and technology dependence, SICS remains a pragmatic alternative to PHACO in resource-limited settings.