Abstract

Phacoemulsification is the current standard surgical technique for cataract extraction because of its safety, minimal incision requirement, and rapid visual recovery. Despite continuous technological advances, corneal endothelial cell damage remains an important concern after surgery, particularly in patients with pre-existing endothelial dysfunction. Since corneal endothelial cells have limited regenerative capacity, excessive cell loss can result in postoperative corneal edema, endothelial decompensation, and impaired visual outcomes. This review summarizes the current understand- ing of corneal endothelial alterations associated with phacoemulsification, including endothelial physiology, mechanisms of intraoperative injury, postoperative morphological changes, and major risk factors affecting endothelial survival. Special attention is given to high-risk conditions such as glaucoma, pseudoexfoliation syndrome, and diabetes mellitus, which are associated with increased endothelial vulnerability and delayed corneal recovery. Current evidence suggests that endothe- lial cell loss after phacoemulsification is influenced by multiple factors, including cataract density, ultrasound energy, cumulative dissipated energy, surgical duration, fluidics, ocular comorbidities, and surgical technique. Modern approaches such as torsional phacoemulsification, optimized flu- idics, reduced ultrasound energy, femtosecond laser-assisted cataract surgery, and the appropriate use of dispersive ophthalmic viscosurgical devices may help minimize endothelial injury. Careful preoperative endothelial assessment, individualized surgical planning, and endothelial-protective strategies are essential to preserve corneal clarity and improve postoperative outcomes, especially in eyes at high risk of endothelial decompensation.