Soft-shell phacoemulsification in Fuchs’ endothelial dystrophy: Central corneal thickness as a predictor of post-operative keratoplasty

Background To identify predictors of unplanned endothelial keratoplasty after phacoemulsification in Fuchs’ endothelial corneal dystrophy (FECD), and to assess postoperative best-corrected visual acuity (BCVA). Methods Retrospective single-centre case series of 50 eyes (39 patients) that underwent soft-shell phacoemulsification and monofocal intra-ocular lens implantation by one surgeon (2015–2021). The primary outcome was unplanned corneal decompensation requiring endothelial keratoplasty. Associations with specular-microscopy parameters and central corneal thickness (CCT) were examined with penalised logistic and Cox regressions adjusted for age, sex, and hypertonic-saline use. Postoperative BCVA was analysed using linear regression models also adjusted for baseline acuity. Results Mean age was 74 ± 8 years; 68% were women; median follow-up 32 (IQR 24–40) months. Four eyes (8%) required Descemet stripping endothelial keratoplasty a median 8 months after cataract surgery. Each 1 μm increase in pre-operative CCT raised the hazard of grafting by 2% (HR 1.02, 95% CI 1.00–1.04, P = 0.031); a threshold of ≥ 620 μm yielded an AUC of 0.91. Linear regression analyses of postoperative BCVA adjusted for preoperative BCVA showed no clear association between baseline and postoperative acuity. Conclusions Pre-operative CCT shows the strongest association of readily available metrics with post-phaco corneal failure in FECD; values above ∼600 μm may warrant counselling regarding combined or staged keratoplasty.