Beyond Visual Acuity: Preserving Corneal Endothelial Integrity in the Era of Modern Cataract Surgery

Background: Modern cataract surgery has progressed beyond simply removing the opaque lens; it now focuses on achieving rapid and high-quality visual recovery with minimal damage to surrounding ocular structures. Among these, the corneal endothelium plays a vital role in maintaining corneal clarity, yet it has very limited regenerative capacity. Any surgical trauma can therefore have lasting implications. The present study aimed to evaluate and compare the morphological and functional changes of the corneal endothelium following two commonly performed cataract procedures—Phacoemulsification and Small-Incision Cataract Surgery (SICS). Methods: This prospective, observational, comparative study was conducted at a tertiary care hospital in Central India between May 2023 and October 2024. A total of 250 patients diagnosed with senile cataract were included and equally allocated into two groups: Phacoemulsification (n = 125) and SICS (n = 125). Corneal endothelial morphology and Endothelial Cell Density (ECD) were assessed using specular microscopy. Functional recovery of the endothelium was evaluated through measurements of Central Corneal Thickness (CCT) using ultrasound pachymetry. Assessments were performed preoperatively and during follow-up visits on postoperative day 1, at 1 month, and at 3 months. Results: Both surgical techniques resulted in a statistically significant but comparable reduction in endothelial cell density from baseline. At the three-month follow-up, the mean endothelial cell loss was approximately 15.5% in both the Phacoemulsification and SICS groups (p = 0.88). Morphological analysis demonstrated expected physiological remodeling of the endothelial layer, characterized by mild pleomorphism and polymegethism. Central corneal thickness showed a transient increase on the first postoperative day in both groups, reflecting temporary corneal edema; however, CCT values returned close to baseline by the one-month follow-up, indicating recovery of endothelial pump function. By the end of three months, nearly 90% of patients in both groups achieved a Best-Corrected Visual Acuity (BCVA) of 6/9 or better. Conclusion: Both Phacoemulsification and Small-Incision Cataract Surgery provide excellent surgical outcomes with comparable safety for the corneal endothelium. When performed with appropriate intraoperative protection, both procedures allow effective endothelial recovery and favourable visual rehabilitation.