Protective Effect of Preoperative Intraocular Pressure Reduction on Corneal Endothelium in Cataract Surgery

Yong Sun Ahn; Yang Kyung Cho

doi:10.7469/JKOS.2015.56.04.521

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Ahn and Cho: Protective Effect of Preoperative Intraocular Pressure Reduction on Corneal Endothelium in Cataract Surgery

Original Article

J Korean Ophthalmol Soc 2015;56(4):521-531.

Published online: 7 September 2015

DOI: https://doi.org/10.7469/JKOS.2015.56.04.521

Protective Effect of Preoperative Intraocular Pressure Reduction on Corneal Endothelium in Cataract Surgery

Yong Sun Ahn, MD, Yang Kyung Cho, MD, PhD

Department of Ophthalmology and Visual Science, The Catholic University of Korea College of Medicine, Seoul, Korea

￭ Address reprint requests to Yang Kyung Cho, MD, PhD Department of Ophthalmology, College of Medicine, The Catholic University of Korea, St. Vincent’s Hospital, #93 Jungbu-daero, Paldal-gu, Suwon 442-723, Korea Tel: 82-31-249-7343, Fax: 82-31-251-6225 E-mail: yangkyeung@hanmail.net

Received 1 May 201417 November 2014 Accepted 24 March 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

초록

Purpose:

To evaluate whether intraocular pressure reduction by intravenous injection of mannitol before phacoemulsification‐ cataract surgery can have a protective effect on corneal endothelium.

Methods:

Patients undergoing sequential bilateral cataract surgery were divided into 2 groups, 36 eyes with anterior chamber depth (ACD) ˂ 2.50 mm (group A) and 44 eyes with ACD ≥ 2.50 mm (group B). In each group, preoperative intravenous injection of mannitol was performed in 1 randomly selected eye of the patient. The specular microscopic examination including cell density (ECD), coefficient of variation (CV), hexagonality (HA) of corneal endothelium, and corneal thickness was performed on postoperative 1 day, 2 weeks, and 5 weeks. In each group, the parameters were compared between the eyes with mannitolization and the contralateral eyes without mannitolization.

Results:

In group A, eyes with preoperative mannitolization showed significantly higher ECD at postoperative 1 day and 5 weeks and showed a significantly thinner cornea at postoperative 1 day than those without mannitolization (all p < 0.05). However, in group B, there was no significant difference of ECD, CV, HA, and corneal thickness between the eyes with and without mannitolization.

Conclusions:

Preoperative intraocular pressure reduction by mannitolization before phacoemulsification can protect the corneal endothelial cells and recover the early postoperative period visual acuity in eyes with shallow anterior chamber.

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Keywords: Corneal endothelium, Mannitol, Microphthalmos, Phacoemulsification, Shallow anterior chamber

References

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Figure 1.

Comparison of mannitolization on postoperative endothelial cell density (mean ± S.E.M, cells/mm²) between group A (ACD < 2.5 mm) and group B (ACD ≥ 2.5 mm). Student’s t-test was used. ^* Statistically significant differences among groups ( p < 0.05). SEM = standard error of mean; ACD = anterior chamber depth; POD = postoperative day.

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Figure 2.

Comparison of mannitolization on postoperative endothelial cell polymegathism (coefficient of variation, mean ± S.E.M) between group A (ACD < 2.5 mm) and group B (ACD ≥ 2.5 mm). Student’s t-test was used. ^* Statistically significant differences among groups ( p < 0.05). SEM = standard error of mean; ACD = anterior chamber depth; POD = postoperative day.

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Figure 3.

Comparison of mannitolization on postoperative endothelial cell hexagonality (mean ± S.E.M, %) between group A (ACD < 2.5 mm) and group B (ACD ≥ 2.5 mm). SEM = standard error of mean; ACD = anterior chamber depth; POD = postoperative day. Student’s t-test was used.

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Figure 4.

Comparison of mannitolization on postoperative corneal thickness (mean ± S.E.M, μ m) between group A (ACD < 2.5 mm) and group B (ACD ≥ 2.5 mm). SEM = standard error of mean; ACD = anterior chamber depth; POD = postoperative day. Student’s t-test was used. ^* Statistically significant differences among groups ( p < 0.05).

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Figure 5.

Comparison of mannitolization on best corrected visual acuity (log MAR, mean ± S.E.M) between group A (ACD < 2.5 mm) and group B (ACD ≥ 2.5 mm). SEM = standard error of mean; ACD = anterior chamber depth; POD = postoperative day. Student’s t-test was used. ^* Statistically significant differences among groups ( p < 0.05).

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Figure 6.

Comparison of mannitolization on intraocular pressure (mean ± S.E.M, mm Hg) between group A (ACD < 2.5 mm) and group B (ACD ≥ 2.5 mm). SEM = standard error of mean; ACD = anterior chamber depth; POD = postoperative day. Student’s t-test was used.

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Table 1.

Preoperative clinical characteristics of each group according to the ACD

Characteristic		Group A (ACD < 2.5 mm)(n = 36)	Group B (ACD ≥ 2.5 mm)(n = 44)	p-value
Sex^* (number of male:female)		18:18	16:28	0.220
Laterality^* (number of right eye:left eye)		18:18	22:22	1.000
Age^† (years)		68.94 ± 0.83	70.00 ± 0.80	0.364
BCVA (log MAR)^†		0.49 ± 0.04	0.48 ± 0.04	0.886
IOP^† (mm Hg)		13.67 ± 0.45	13.34 ± 0.46	0.619
Axial length^† (mm)		22.86 ± 0.09	24.07 ± 0.11	<0.001^‡
ACD^† (mm)		2.16 ± 0.04	3.11 ± 0.03	<0.001^‡
Corneal endothelium	Cell density^† (cells/mm²)	2622.19 ± 54.33	2663.16 ± 55.99	0.606
	Coefficient of variation^†	33.86 ± 1.25	33.75 ± 0.74	0.939
	Hexagonality^† (%)	57.72 ± 1.54	57.41 ± 1.43	0.882
Corneal thickness^† (μ m)		551.81 ± 3.99	558.80 ± 4.18	0.237
Nuclear opacity (LOCS III)^*		3.83 ± 0.81	3.84 ± 0.81	0.997

Values are presented as mean ± SD or number.

BCVA = best corrected visual acuity; IOP = intraocular pressure; ACD = anterior chamber depth; LOCS = lens opacities classification system III.

^* Pearson's Chi-square test was used for numeric parameters;

^† Student’s t-test was used for continuous parameters;

^‡ Statistically significant differences ( p-value<0.05) among groups.

Table 2.

Comparison of postoperative outcome of each group according to ACD over time

			Group A (ACD < 2.5 mm)(n = 36)	Group B (ACD ≥ 2.5 mm)(n = 44)	p-value
Total operation time^* (min)			11.42 ± 0.67	10.50 ± 0.40	0.246
Phaco energy^*			407.38 ± 29.89	412.84 ± 22.29	0.884
BCVA (log MAR)^*		POD #1 day	0.21 ± 0.02	0.16 ± 0.01	0.026^‡
		POD #2 weeks	0.08 ± 0.01	0.08 ± 0.01	0.758
		POD #5 weeks	0.07 ± 0.01	0.07 ± 0.01	0.967
IOP^* (mm Hg)		POD #1 day	11.53 ± 0.42	12.45 ± 0.56	0.187
		POD #2 weeks	11.50 ± 0.29	11.89 ± 0.38	0.438
		POD #5 weeks	11.56 ± 0.38	11.57 ± 0.39	0.982
Corneal endothelium	Cell density^* (cells/mm²)	POD #1 day	2475.56 ± 45.71	2651.41 ± 62.83	0.027^‡
Corneal endothelium	Cell density^* (cells/mm²)	POD #2 weeks	2476.44 ± 46.98	2652.66 ± 60.44	0.024^‡
		POD #5 weeks	2473.03 ± 44.70	2653.41 ± 59.95	0.018^‡
	Coefficient of variation^*	POD #1 day	38.75 ± 1.23	35.27 ± 0.59	0.014^‡
	Coefficient of variation^*	POD #2 weeks	35.47 ± 1.23	34.23 ± 0.75	0.390
		POD #5 weeks	35.36 ± 1.08	34.39 ± 0.70	0.437
	Hexagonality^* (%)	POD #1 day	52.31 ± 1.55	54.05 ± 1.35	0.398
		POD #2 weeks	55.11 ± 1.48	54.09 ± 1.36	0.613
		POD #5 weeks	56.19 ± 1.42	54.50 ± 1.35	0.392
Corneal thickness^* (μ m)		POD #1 day	587.56 ± 7.49	569.75 ± 4.27	0.043^‡
		POD #2 weeks	553.44 ± 3.78	560.02 ± 4.09	0.250
		POD #5 weeks	551.89 ± 3.57	559.45 ± 4.17	0.183
Descemet’s membrane folding^† (number of eyes)		POD #1 day	8	7	0.472
Anterior chamber inflammation^*		POD #1 day	1.39 ± 0.10	1.28 ± 0.09	0.420

Values are presented as mean ± SD (standard error of mean); Phaco energy: mean ultrasound power x ultrasound time; Anterior chamber inflammation is graded by SUN¹¹ criteria.

BCVA = best corrected visual acuity; IOP = intraocular pressure; ACD = anterior chamber depth; POD = postoperative day.

^* Student’s t-test was used for continuous parameters;

^† Pearson's Chi-square test was used for numeric parameters;

^‡ Statistically significant differences ( p-value < 0.05) among groups.

Table 3.

Preoperative clinical characteristics between patients with preoperative mannitolization and without preoperative mannitolization in group A (ACD < 2.5 mm) & in group B (ACD ≥ 2.5 mm)

		Group A (ACD < 2.5 mm) (n = 36)			Group B (ACD ≥ 2.5 mm) (n = 44)
		Mannitol (+)(n = 18)	Mannitol (-)(n = 18)	p-value	Mannitol (+)(n = 18)	Mannitol (-)(n = 18)	p-value
BCVA (log MAR)^*		0.47 ± 0.05	0.51 ± 0.06	0.611	0.50 ± 0.06	0.47 ± 0.05	0.759
IOP^* (mm Hg)		13.94 ± 0.74	13.39 ± 0.53	0.545	13.68 ± 0.63	13.00 ± 0.68	0.466
Axial length^* (mm)		22.87 ± 0.14	22.84 ± 0.13	0.876	24.06 ± 0.15	24.09 ± 0.16	0.887
ACD^* (mm)		2.14 ± 0.06	2.17 ± 0.05	0.711	3.11 ± 0.05	3.11 ± 0.04	0.966
Corneal endothelium	Cell density^*(cells/mm²)	2,620.61 ± 48.06	2,623.78 ± 99.22	0.977	2,634.09 ± 75.17	2,692.23 ± 84.30	0.609
	Coefficient of variation^*	33.50 ± 1.80	34.22 ± 1.79	0.777	34.00 ± 0.88	33.50 ± 1.21	0.740
	Hexagonality^* (%)	58.00 ± 1.03	57.44 ± 2.95	0.860	57.36 ± 1.95	57.45 ± 2.13	0.975
Corneal thickness^* (μ m)		553.11 ± 5.24	550.50 ± 6.14	0.748	558.36 ± 6.08	559.23 ± 5.89	0.919
Nuclear opacity (LOCS III)^†		3.83 ± 0.79	3.83 ± 0.86	0.774	3.82 ± 0.80	3.86 ± 0.83	0.924
Total operation time^* (min)		10.71 ± 0.76	12.12 ± 1.10	0.301	10.42 ± 0.56	10.58 ± 0.60	0.843
Phaco energy^*		406.27 ± 40.75	408.49 ± 44.92	0.971	412.43 ± 25.45	413.25 ± 37.24	0.986

Values are presented as mean ± SD; Phaco energy: mean ultrasound power x ultrasound time.

BCVA = best corrected visual acuity; IOP = intraocular pressure; ACD = anterior chamber depth; LOCS = lens opacities classification system III.

^* Student’s t-test was used for continuous parameters;

^† Pearson's Chi-square test was used for numeric parameters.

Table 4.

Comparison of postoperative descemet’s membrane and anterior chamber inflammation between patients with preoperative mannitolization and without preoperative mannitolization in group A (ACD < 2.5 mm) & in group B (ACD ≥ 2.5 mm) at postoperative day 1

	Group A (ACD < 2.5 mm) (n = 36)			Group B (ACD ≥ 2.5 mm) (n = 44)
	Mannitol (+)(n = 18)	Mannitol (-)(n = 18)	p-value	Mannitol (+)(n = 22)	Mannitol (-)(n = 22)	p-value
Descemet’s membrane folding^*(number of eyes)	3	5	0.423	2	5	0.216
Anterior chamber inflammation^†	1.33 ± 0.13	1.44 ± 0.14	0.569	1.27 ± 0.13	1.30 ± 0.12	0.897

Values are presented as mean ± SD or number; Anterior chamber inflammation is graded by SUN¹¹ criteria.

ACD = anterior chamber depth.

^* Pearson's Chi-square test was used for numeric parameters;

^† Student’s t-test was used for continuous parameters.

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