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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 20  |  Issue : 1  |  Page : 134-141

Comparison of corneal changes after phacoemulsification in diabetic and nondiabetic eyes


1 Cairo, Egypt
2 Department of Ophthalmology, Al-Azhar University Hospital, Ophthalmology, Cairo, Egypt

Date of Submission11-Nov-2021
Date of Decision30-Nov-2021
Date of Acceptance06-Dec-2021
Date of Web Publication4-Mar-2022

Correspondence Address:
MBBCh Asmaa Ibrahim Elminshawy
Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/azmj.azmj_130_21

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  Abstract 


Background and aim Endothelium of the cornea is susceptible to surgical trauma during phacoemulsification from ultrasound energy. Several studies have reported various results of corneal changes after phacoemulsification in diabetic and healthy patients. The aim was to evaluate and compare changes in precorneal tear film, anterior and posterior corneal surfaces, endothelial cell changes, and central corneal thickness (CCT) between diabetic and healthy patients before and after uneventful phacoemulsification.
Patients and methods A total of 40 eyes of 40 patients who were scheduled for cataract surgery were divided into group 1 (20 eyes in nondiabetic patients) and group 2 (20 eyes in diabetic patients). Ophthalmological examinations, including uncorrected and best-corrected visual acuity (BCVA), slit lamp to examine anterior and posterior corneal surfaces, tear film breakup time test (TBUT), anterior chamber depth by IOL Master (Topcon ALADDIN HW2.0), and specular microscopy (Topcon SP-1P, made In Japan), were done preoperatively and at 1 week, 1 month, and 3 months postoperatively.
Results Significant differences were found between preoperative and postoperative periods in both groups regarding BCVA, TBUT, CCT, endothelial cell density (ECD), coefficient of variation, and hexagonal cells, except that changes became insignificant with respect to CCT at 3 months in nondiabetic and at 1 week and 3 months in diabetic and in CD at 1 month in healthy patients.
Conclusion There were significant changes in BCVA, TBUT, CCT, and ECD after phacoemulsification in the diabetic and healthy groups. There was a significant delay in the recovery of CCT 1 month after phacoemulsification in the diabetic compared with healthy individuals.

Keywords: CCT, ECD, TBUT, phacoemulsification


How to cite this article:
Elminshawy AI, Hegazy HS, Aly MM. Comparison of corneal changes after phacoemulsification in diabetic and nondiabetic eyes. Al-Azhar Assiut Med J 2022;20:134-41

How to cite this URL:
Elminshawy AI, Hegazy HS, Aly MM. Comparison of corneal changes after phacoemulsification in diabetic and nondiabetic eyes. Al-Azhar Assiut Med J [serial online] 2022 [cited 2022 Jun 29];20:134-41. Available from: http://www.azmj.eg.net/text.asp?2022/20/1/134/339064




  Introduction Top


Cataract has been the most significant cause of bilateral blindness. The preferred technique for most types of cataract is phacoemulsification owing to rapid visual recovery, decreased astigmatism, and decreased postoperative inflammation. The patients are usually above 50 years, and this might have a less prognosis after surgery because increasing age was associated with decrease of endothelial cells [1]. The hexagonal (HEX) cells of the endothelium are responsible for maintaining the clarity of the cornea by actively removing the water [2]. Several studies have focused on corneal abnormalities after cataract surgery in diabetic and healthy patients. Diabetic cornea is more vulnerable to trauma and stress, resulting in morphological abnormalities and delayed recovery [3]. A study done by Saghizadeh et al. [4] found an impairment of the epithelial basement membrane and epithelial-stromal interactions in diabetic patients, so the cornea in diabetic patient is more at risk of developing epithelial defects and recurrent erosions. Dry eye in diabetic patients is higher than in nondiabetic. Dryness is detected by tear film breakup time test (TBUT) using stain. Normal TBUT is >10 s. A study done by Tao et al. [5] found significant changes in cornea between diabetic and healthy patients. The cornea thickness is evaluated by central corneal thickness (CCT) (normally 557.61±49.92 µm3), and endothelium of the cornea is evaluated by cell density (CD) (normal value at least 2500 cells/mm2) and morphology (coefficient of variation [CV]: normal value up to 30% and HEX: normal value above 60%).

The aim of this study was to evaluate and compare the changes in precorneal tear film, anterior and posterior corneal surfaces, corneal endothelial cell changes, and CCT between diabetic and healthy patients before and after uneventful phacoemulsification.


  Patients and methods Top


This study included 40 eyes of 40 patients and was carried out at the Department of Ophthalmology, Al-Azhar University Hospitals in the period between February 2021 and November 2021. The protocol of the study adhered to the tenets of the Declaration of Helsinki and was approved by the Ethical Board of Al-Azhar University. An informed written consent was taken from each participant after illustrating the study purpose, and they had the right to accept or not.

Study design

A prospective, interventional, comparative case series was performed.

The patients were divided into two groups:
  1. Group 1: 20 eyes with cataract in healthy patients.
  2. Group 2: 20 eyes with cataract in diabetic patients.


Inclusion criteria

Age from 40 to 60 years, nuclear grade up to 3 with cortical or posterior subcapsular cataract according to LOCS III cataract grading, preoperative anterior chamber depth (ACD) of at least 2.5 mm, and preoperative endothelial cell density (ECD) (at least 1500 cells/ mm2) were the inclusion criteria.

Exclusion criteria

Any corneal pathology; pseudoexfoliation; history of ocular trauma, intraocular surgery, or inflammation; and age younger than 40 years were the exclusion criteria.

Study tools and procedures

Preoperative examinations included the following:
  1. History of ocular trauma, ocular surgery, systemic disorder, and drug intake, as well as onset, course, and duration of diminution of vision.
  2. Fasting blood glucose and 2-h postprandial blood glucose.
  3. Coagulation profile and liver and kidney function tests.
  4. Calculation of Intra Ocular Lens power (IOL) power, ACD, and axial length.


A complete ocular examination in preoperative and postoperative visits included the following:
  1. Uncorrected and best-corrected visual acuity (UCVA and BCVA).
  2. Slit-lamp biomicroscopy for assessment of precorneal tear film by TBUT for dryness; anterior corneal surface for clarity, edema, and ulcers; posterior corneal surface for deposits; anterior chamber (depth and contents); and any iris abnormality.
  3. Indirect ophthalmoscopy for fundus examination.
  4. Intraocular pressure measurement with applanation tonometry.
  5. Specular microscopy: the ECD (cells/mm2), CV, HEX, and CCT.


Statistical analysis

Statistical analysis was achieved using independent t-test for the comparison between two groups (group 1: 20 diabetic patients and group 2: 20 nondiabetic patients). The confidence interval was set to 95%, and the accepted error margin accepted was up to 5%.

So, the P value was considered significant as follows:
  1. P>0.05 means it is not statistically significant.
  2. P<0.05 means it is statistically significant.
  3. P<0.01 means it is statistically highly significant.



  Results Top


The study included 40 eyes of 40 patients classified into two groups: group 1: 20 diabetic patients and group 2: 20 nondiabetic patients.

Changes in best-corrected visual acuity (BCVA)

Our research shows a gradual change in BCVA. In group 1, there were significant changes between the mean preoperative BCVA value (0.77±0.16) and postoperative values (0.12±0.21, 0.12±0.20, and 0.07±0.12 at 1 week, 1 month, and 3 months), with P value <0.05. In group 2, there were significant changes between the mean preoperative BCVA value (0.92±0.22) and postoperative values (0.12±0.16, 0.18±0.21, 0.10±0.14 at 1 week, 1 month, and 3 months), with P value <0.05. There was a preoperative significant difference between the two groups, with P value <0.05, but there were postoperative insignificant differences at 1 week, 1 month, and 3 months, with P>0.05 ([Table 1]).
Table 1 Progressive changes in BCVA in both groups

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Changes in tear film breakup time test (TBUT)

Our research shows a gradual change in TBUT. In group 1, there was a significant change between the mean TBUT value preoperatively (9.30±1.82) and postoperatively (6.50±1.40, 6.15±1.47, 8.43±1.55, and 10.55±1.39 at 1 day, 1 week, 1 month, and 3 months), with P=0.000. In group 2, there was a significant change between the mean TBUT value preoperatively (7.63±1.86) and postoperatively (4.40±1.24, 4.05±0.99, and 5.73±1.43 at 1 day, 1 week, and 1 month, respectively, with P=0.000, except for a postoperative insignificant change at 3 months (7.75±1.77), with P=0.171. There were preoperative and postoperative significant differences between the two groups at 1 day, 1 week, 1 month, and 3 months, with P<0.05 ([Table 2]).
Table 2 Progressive changes in TBUT in both groups

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Changes in central corneal thickness (CCT)

Our research shows a gradual change in CCT. In group 1, there was a significant change between the mean CCT preoperatively (528.40±29.19) and postoperatively (546.20±27.45 and 545.75±30.91 at 1 week and 1 month), with P value <0.05, but there was a postoperative insignificant change at 3 months (532.90±30.02), with P value >0.05. In group 2, there was a significant change between the mean CCT preoperatively (519.55±22.37) and postoperatively (536.35±20.84 at 1 month), with P value <0.05, but there were postoperative insignificant changes at 1 week and 3 months (527.30±31.94 and 514.85±32.25, respectively), with P value >0.05. There were preoperative and postoperative insignificant differences between the two groups at 1 week, 1 month, and 3 months, with P>0.05 ([Table 3]).
Table 3 Progressive changes in central corneal thickness (CCT) in both groups

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Changes in cell density

Our research shows a gradual change in CD. In group 1, there was an insignificant change between the mean CD value preoperatively (2791.15±503.84) and postoperatively (2700.35±401.31 at 1 month), with P value >0.05, but there was a postoperative significant change at 3 months, with P value <0.05. In group 2, there was a significant change preoperative (2778.40±330.72) and postoperatively (2567.85±326.50 and 2370.00±327.84 at 1 month and 3 months, respectively), with P value <0.05. There were preoperative and postoperative insignificant differences between the two groups at 1 week, 1 month, and 3 months, with P>0.05 ([Table 4]).
Table 4 Progressive changes in cell density (CD) in group 1 and group 2

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Changes in coefficient of variation (CV)

Our research shows a gradual change in CV. In group 1, there was a significant change between the mean CV preoperatively (34.95±3.03) and postoperatively (37.40±5.76 and 37.35±3.28 at 1 month and 3 months, respectively), with P value <0.05. In group 2, there was a significant change between the mean CV preoperatively (36.25±3.18) and postoperatively (37.25±3.18 and 39.40±3.32 at 1 month and 3 months respectively), with P value <0.05. There were preoperative and postoperative insignificant differences between the two groups at 1 month and 3 months, with P>0.05 ([Table 5]).
Table 5 Progressive changes in coefficient of variation (CV) in group 1 and group 2

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Changes in percentage of hexagonally (HEX)

Our research shows a gradual change of HEX. In group 1, there was a significant change in the mean HEX preoperatively (34.30±6.02) and postoperatively (29.00±6.35 and 28.65±6.97 at 1 month and 3 months, respectively), with P value <0.05. In group 2, there was a significant change in the mean HEX preoperatively (32.60±5.33) and postoperatively (24.60±5.33 and 23.90±4.41 at 1 month and 3 months, respectively), with P value <0.05. There were postoperative significant differences between the two groups at 1 week, 1 month, and 3 months, with P<0.05, but there was a preoperative insignificant difference, with P>0.05 ([Table 6]).
Table 6 Progressive changes in percentage of hexagonally (HEX) in group 1 and group 2

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Our research has shown that there were postoperative significant correlations between group 1 and group 2 regarding CD at 1 month and 3 months, CV at 3 months, HEX at 1 month and 3 months, and CCT and CV at 1 month, but there was a postoperative insignificant correlation between group 1 and group 2 regarding BCVA at 1 week, 1 month, and 3 months and CCT at 1 week and 3 months ([Table 7]).
Table 7 Correlation between group 1, 2, and BCVA, CCT, CD, CV, XEX

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  Discussion Top


The main aim of this study was to evaluate and compare the changes in anterior and posterior corneal surfaces, corneal endothelial cell changes, and CCT between diabetic and healthy population before and after phacoemulsification surgery. According to the reported results after cataract surgery, the loss of CD in diabetic patients was 5.95% to 29.07%, whereas was 0.88% to 18.18% in the healthy population [6]. Our study included 20 diabetic (group 1) and 20 nondiabetic patients (group 2) (50.0%). The present study showed that preoperative UCVA in the nondiabetic group was better than the diabetic group, with a P value of 0.038, which was significant. BCVA was found to be better in the nondiabetic group than the diabetic group. There were significant changes in both groups preoperatively and postoperatively. There were significant differences between the two groups preoperatively, with P value <0.05. However, insignificant differences were found between the two groups postoperatively at all periods of follow-up, with P>0.05. Our results match with the study by ELKady et al. [7], which found significant changes between preoperative and postoperative values in both groups. Our study showed that preoperative TBUT in the nondiabetic group was higher than that in the diabetic group. There were significant changes of TBUT in both groups preoperatively and postoperatively, except at 3 months in group 2, where insignificant changes were found, with P=0.171. There were significant differences between two groups at all periods of follow-up, with P<0.05. In this study, regarding CCT, there were significant changes at 1 week in group 1 and at 1 month in both groups, with P value <0.05, but insignificant changes were found at 1 week in group 2 and at 3 months in both groups, with P value >0.05. There were insignificant differences between the two groups all before follow-up, with P>0.05. Our results match with the study by Khokhar et al. [8], which found no differences in CCT between the two groups, and the study by Tang et al. [9], which found significant differences in CCT postoperatively at 1 month. However, no significant differences were found postoperatively at 1 week and 3 months. However, our results did not match with the study by Abdelhalem et al. [10], which found significant changes in CCT in both groups after phacoemulsification. In this study, regarding CD, there were significant changes at 1 month in group 2 and at 3 months in both groups, with P value >0.05, but insignificant changes were found at 1 month in group 1, with P value <0.05. There were insignificant differences between the two groups postoperatively at 1 month and 3 months, with P>0.05. Our results match with the study by Fernandez-Muñoz et al. [11], which found an insignificant difference in ECD between groups preoperatively (P=0.417) and the study by Joo and Kim [12], which found a significant difference in ECD in the DM compared with the control group. In this study, regarding CV, there were significant changes in the two groups postoperatively at 1 month and at 3 months, with a P value <0.05, whereas there were insignificant differences between the two groups at all periods of follow-up, with P>0.05. Our results match with the study by Dandaliya et al. [13], which found a significant change in %CV between diabetic and healthy groups and between preoperative and postoperative periods, and the study by Tang et al. [9], which found significant changes in CV at 1 month postoperatively. In this study, regarding HEX, there were significant changes in the two groups preoperative and postoperatively at 1 month and 3 months, with P value <0.05. There were significant differences between the two groups postoperatively at 1 month and 3 months, with P<0.05. Our results match with the study by Budiman [14], which found differences in HEX at 4 weeks after phacoemulsification between diabetic and healthy groups, and the study by Alotaibi et al. [15], which found significant changes in the HEX cell % postoperatively, with P<0.001.

Limitations

Small number of patients and short-term follow-up period were the limitations of this study.


  Conclusion Top


There were significant changes in BCVA, TBUT, CCT, and ECD after phacoemulsification in the diabetic and nondiabetic groups. There was a significant delay in the recovery of CCT 1 month after phacoemulsification in diabetic compared with the healthy group.

Recommendation

We do recommended corneal assessment by specular microscopy as a part of the routine examination for patients after phacoemulsification in diabetic and nondiabetic cases ([Figure 1] and [Figure 2]).
Figure 1 Coreal changes before and after phacoemulsification by specular microscopy in non diabetic group.

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Figure 2 Coreal changes before and after phacoemulsification by specular microscopy in diabetic group.

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khan A, Kose S, Jharwal M, Meena A, Sharma A. Comparison of corneal endothelial cell counts in patients with controlled diabetes mellitus (Type 2) and non diabetics after phacoemulsification and intraocular lens implantation. International Multispecialty Journal of Health 2019; 2:6.  Back to cited text no. 1
    
2.
Morikubo S, Takamura Y, Kubo E. Corneal changes after small-incision cataract surgery in patients with diabetes mellitus. Arch Ophthalmol 2017; 122:966–969.  Back to cited text no. 2
    
3.
Lee J, Lee J, Choi H. Corneal endothelial cell changes after phacoemulsification relative to the severity of diabetic retinopathy. J Cataract Refract Surg 2018; 31:742–749.  Back to cited text no. 3
    
4.
Saghizadeh M, Kramerov A, Yu F-SX, Castro MG, Ljubimov AV. Normalization of wound healing and diabetic markers in organ cultured human diabetic corneas by adenoviral delivery of c-Met gene. Invest Ophthalmol Vis Sic 2014; 51:1970–1980.  Back to cited text no. 4
    
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Tao A, Chen Z, Shao Y. Phacoemulsification induced transient swelling of corneal Descemet’s endothelium complex imaged with ultra-high resolution optical coherence tomography. Invest Ophthalmol Vis Sic 2017; 9:545–560.  Back to cited text no. 5
    
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Ganesan N, Srinivasan R, Babu KR, Vallinayagam M. Risk factors for endothelial cell damage in diabetics after phacoemulsification. Oman J Ophthalmol 2019; 12:94.  Back to cited text no. 6
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ELKady MS, Saleh MM, Aboalhamd AS. Corneal endotheleal cells changes after phacoemulsification in type II diabetes mellitus. Egypt J Hosp Med 2017; 69:2004–2011.  Back to cited text no. 7
    
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Khokhar S, Sen S, Dhull C. Active-fluidics-based torsional phacoemulsification in diabetic eyes: a prospective interventional study. Indian J Ophthalmol 2019; 67:619.  Back to cited text no. 8
    
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Tang Y, Chen X, Zhang X, Tang Q, Liu S, Yao K. Clinical evaluation of corneal changes after phacoemulsification in diabetic and non-diabetic cataract patients, a systematic review and meta-analysis. Sci Rep 2017; 7:14128.  Back to cited text no. 9
    
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Abdelhalem R, Saif MYS, Mohamed S. Central corneal thickness before and after phacoemulsification in non-diabetic and diabetic patients without retinopathy. NILES Journal for Geriatric and Gerontology, 3 (Geriatric Ophthalmology) 2020; 3:15–22.  Back to cited text no. 10
    
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Fernández-Muñoz E, Zamora-Ortiz R, Gonzalez-Salinas R. Endothelial cell density changes in diabetic and non-diabetic eyes undergoing phacoemulsification employing phaco-chop technique. Int Ophthalmol 2019; 39:1735–1741.  Back to cited text no. 11
    
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Joo JH, Kim TG. Comparison of corneal endothelial cell changes after phacoemulsification between type 2 diabetic and non-diabetic patients. Medicine 2021; 100:e 27141.  Back to cited text no. 12
    
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Dandaliya I, Bedi DK, Nainiwal SK. Evaluation of corneal endothelial cell changes in diabetic patients before and after phacoemulsification surgery: a comparative study. Indian J Clin Exp Ophthalmol 2018; 4:458–464.  Back to cited text no. 13
    
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Budiman B. Comparison of endothelial cell density, morphological changes and central corneal thickness after phacoemulsification between diabetic and non-diabetic patients. Open Ophthalmol J 2020; 14:15–20.  Back to cited text no. 14
    
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Alotaibi FA, Alosaimi RA, Alyahya FA, Alali MM, Ayidh FA, Alanazi FM et al. Meta-analysis on corneal changes following phacoemulsification in diabetic vs. non-diabetic cataract patients. Egypt J Hosp Med 2018; 70:754–761.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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