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Intraocular endothelial Keratogel Device for protection corneal endothelium during phacoemulsification cataract surgery

Eye volume 39, pages 622–623 (2025)Cite this article

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Phacoemulsification cataract surgery is one of the most commonly performed ophthalmic surgeries globally. The technique entails the use of high-intensity ultrasound to break the cataractous lens into smaller fragments which are then emulsified [1]. However, the use of high ultrasound energy, especially in hard cataracts [2], the use of other instruments, an increase in aqueous temperature [3, 4] and cataract fragments colliding with the endothelium [5], can cause damage to corneal endothelium resulting in endothelial cell loss during phacoemulsification. Studies have reported 11–20% endothelial cell loss following phacoemulsification cataract surgery [6, 7]. Even in the best intrasurgical scenarios, a minimum of 2% endothelial cell loss has been reported [8]. Since endothelium does not have the regenerative capacity, severe endothelial cell loss leads to corneal oedema and progresses to pseudophakic bullous keratopathy (PBK). This is almost inevitable if the endothelial cell density falls below 500 cells/mm2 [9]. Preoperative endothelial cell count is therefore important to predict PBK and such eyes need endothelial protection during phacoemulsification.

Some of the commonly used dispersive OVDs include Viscoat (Alcon), Ocucoat (Bausch & Lomb), Healon D (Johnson & Johnson), and DisCoVisc (Alcon). Healon 5 (Johnson & Johnson) was introduced as a viscoadaptive substance with cohesive properties as well as dispersive properties under appropriate conditions [12]. These properties of OVDs were used in the soft shell technique described by Dr Steve Arshinoff [13]. In this technique, a dispersive OVD is first injected into the eye to coat the endothelium. This is followed by injecting cohesive OVD under it to maintain the anterior chamber and a flat anterior lens capsule. This technique helps protect the endothelium during cataract surgery while maintaining adequate depth in the anterior chamber. However, in very dense cataracts and low endothelial cell counts, even a soft shell technique can cause enough damage to endothelial cells resulting in vision-reducing corneal oedema.

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Fig. 1: Schematic showing properties of different types of viscoelsatic agents.

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Authors and Affiliations

  1. L.V. Prasad Eye Institute, Hyderabad, India

    Rashmi Deshmukh

  2. Royal Victorian Eye and Ear Hospital, Melbourne, Australia

    Rasik B. Vajpayee

  3. Vision Eye Institute, Melbourne, Australia

    Rasik B. Vajpayee

  4. University of Melbourne, Melbourne, Australia

    Rasik B. Vajpayee

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  1. Rashmi Deshmukh
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  2. Rasik B. Vajpayee
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Correspondence to Rashmi Deshmukh.

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Deshmukh, R., Vajpayee, R.B. Intraocular endothelial Keratogel Device for protection corneal endothelium during phacoemulsification cataract surgery. Eye 39, 622–623 (2025). https://doi.org/10.1038/s41433-024-03518-y

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