Endothelial Cell Loss After Phacoemulsification in a Romanian Cohort: Early Outcomes and Associated Risk Factors

Background/Objectives: Corneal endothelial damage remains a key concern following phacoemulsification. This study aimed to quantify early postoperative changes in endothelial cell density metrics after cataract surgery in a Romanian population and to identify preoperative and intraoperative predictors of endothelial cell loss at 1 week and 1 month postoperatively. Methods: We conducted a retrospective observational study of 137 eyes that underwent standard phacoemulsification with intraocular lens implantation at Ocularcare Ophthalmology Hospital in Bucharest, Romania. Preoperative data included age, sex, and biometric parameters: anterior chamber depth (ACD), axial length (AL), and central corneal thickness (CCT). Corneal endothelium was assessed by specular microscopy preoperatively and at 1 week and 1 month postoperatively, with measurements of endothelial cell density (CD), number of analyzed cells (No), average cell size (ACS), minimum and maximum cell size (MinCS, MaxCS), and cell size variability (SD). Intraoperative parameters included average ultrasound energy (AVE) and actual phacoemulsification time (APT). Associations between demographic, biometric, and surgical variables and postoperative endothelial changes were analyzed using univariable and multivariable regression models. Results: In 137 eyes, mean CD decreased from 2401.99 ± 342.57 cells/mm² preoperatively to 2144.38 ± 449.92 at 1 week and 2053.15 ± 471.13 at 1 month. CCT increased from 534.64 ± 38.01 µm to 548.70 ± 41.34 µm at 1 week and remained higher than baseline at 1 month (545.67 ± 42.91 µm). Endothelial remodeling was reflected by significant increases in ACS, MaxCS, and SD, while No and MinCS showed no significant change. In adjusted models, lower postoperative CD was independently associated with shallower ACD and lower baseline CD at both timepoints, whereas higher AVE was associated with lower postoperative CD at 1 week but not at 1 month; sex was not independently associated with postoperative CD. Conclusions: In this Romanian cohort, phacoemulsification was associated with significant early endothelial cell loss measurable within the first postoperative month. The magnitude of CD reduction was influenced by both baseline patient ocular characteristics (ACD) and intraoperative phacoemulsification parameters, particularly ultrasound energy (AVE). These findings support the incorporation of preoperative biometric assessment and intraoperative ultrasound minimization strategies to reduce endothelial risk.