Cigarette Smoking as an Independent Predictor of Endothelial Cell Loss After Cataract Surgery: A Prospective Cohort Study

Purpose: To assess the impact of cigarette smoking on corneal endothelial cell density (ECD), central corneal thickness (CCT), and endothelial morphology following cataract surgery in older adults, and to determine whether smoking independently predicts postoperative endothelial cell loss. Methods: Prospective, observational cohort study conducted at the Institute of Ophthalmology, University of Modena and Reggio Emilia. Patients over 40 years of age undergoing cataract surgery were enrolled and classified as smokers or non-smokers. ECD, CCT, polymegathism, and pleomorphism were assessed preoperatively and at 1 and 3 months postoperatively using specular microscopy. Smoking exposure was quantified in Pack-Years. Statistical analyses included Student’s t-tests, multivariate linear regression, and Cohen’s d for effect size estimation. Results: A total of 80 eyes from 80 patients were analyzed. Smokers had significantly lower baseline ECD (2294.8 vs 2523.9 cells/mm 2 ; p = 0.0005) and greater CCT (556.2 vs 538.4 μm; p = 0.004) compared to non-smokers. Postoperative ECD loss was significantly greater in smokers at 1 and 3 months (p < 0.001), with increased CCT and more severe morphological changes. Multivariate analysis confirmed smoking as an independent predictor of endothelial loss (β = − 0.48; p < 0.001). The effect size for ECD reduction was large (Cohen’s d = 1.2). Conclusion: Cigarette smoking is associated with accelerated endothelial cell loss and impaired corneal recovery after cataract surgery. Smoking history should be systematically incorporated into preoperative risk assessments and patient counseling, with consideration for enhanced perioperative monitoring in smokers.