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Editors Selection IGR 9-4

Surgical Treatment: CEC in one- versus two-site phacotrab

Comment by Fotis Topouzis on:

21602 A comparison of corneal endothelial cell changes after 1-site and 2-site phacotrabeculectomy, Nassiri N; Rahnavardi M et al., Cornea, 2008; 27: 889-894

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In a historical cohort study of 169 patients, Nassiri et al. (1269) compare the corneal endothelial cell (CEC) changes after one-site and two-site phacotrabeculectomy (61 and 52 patients respectively) performed by the same surgeon and evaluate factors associated with CEC changes. After a median follow-up of 12 months (range 9 to 24 months), the two operations were found to be similar in improving visual acuity, lowering intraocular pressure and decreasing the number of anti-glaucoma medications. However, two-site surgery was associated with significantly more expansion in the mean CEC area than one-site surgery (p < 0.001). In multivariate analysis longer follow-up, two-site surgery and grade-4 cataract density were associated with more CEC loss, while longer follow-up, two-site surgery and steroid-induced glaucoma were associated with mean CEC area expansion. While interpreting these findings, we need to consider the following. The finding that CEC loss was significantly higher in patients with 4-cataract grading may have been confounded by phaco power, which would be expected to be higher in these cases. Phaco power was found to be significantly correlated with the percentage of CEC loss. As mentioned above, twosite surgery was associated with more CEC loss. However, difference between two-site and one-site surgery was small (16.19% vs. 15.24% decrease in cell density respectively), and one may wonder about the clinical significance of this finding. Also, as the authors explain, the one-site procedure requires the creation of a scleral tunnel, while the 2-site procedure requires a corneal incision. Therefore it would be fair to conclude that the scleral tunnel vs corneal incision and not the one-site vs the two-site phacotrabeculectomy is the real question with regards to postoperative CEC loss. It has been previously reported that phacoemulsification through a scleral tunnel resulted in less postoperative endothelial damage than phacoemulsification through a clear corneal incision.

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