Severe Corneal Endothelial Cell Loss Following FLACS: A Case Report

Femtosecond laser-assisted cataract surgery (FLACS) may reduce ultrasound energy and is often considered favorable for corneal endothelial safety, but clinically relevant endothelial injury can still occur. We report a 60-year-old man with normal preoperative endothelial cell density (ECD) who developed marked corneal edema and Descemet’s folds on the first day after apparently uncomplicated FLACS. No early postoperative specular microscopy was performed, and an intraocular lens (IOL) exchange was subsequently carried out while corneal clarity remained compromised. Several months later, a tertiary center documented an ECD of 743 cells/mm2 and subsequently 634 cells/mm2 in the affected eye, corresponding to a 71–75% reduction from the preoperative value of 2560 cells/mm2, with marked pleomorphism and polymegathism. Marked corneal edema and Descemet’s folds on postoperative day 1 documented clinically significant endothelial dysfunction before the subsequent IOL exchange; however, because ECD was not measured between the two procedures, the final magnitude of endothelial cell loss cannot be attributed exclusively to the initial surgery. Endothelial keratoplasty was discussed, but during approximately two years of follow-up the ECD remained markedly reduced, while the cornea remained clinically stable, and keratoplasty has not been required. This case emphasizes early endothelial assessment when persistent corneal edema or delayed visual recovery follows cataract surgery, particularly before further intraocular intervention.