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The protective effect of ophthalmic viscoelastic devices on endothelial cell loss during cataract surgery: a meta-analysis using mixed treatment comparisons
  1. Ann Van den Bruel1,*,
  2. Jeannine Gailly1,
  3. Stephan Devriese1,
  4. Nicky Welton2,
  5. Alex Shortt3,
  6. France Vrijens1
  1. 1 Belgian Health Care Knowledge Centre, Belgium;
  2. 2 University of Bristol, United Kingdom;
  3. 3 UCL Institute of Ophthalmology, United Kingdom
  1. Correspondence to: Ann Van den Bruel, Belgian Health Care Knowledge Centre, Kruidtuinlaan 55, Brussel, 1000, Belgium; ann.vandenbruel{at}


Background/aims: to compare ophthalmic viscoelastic devices (OVD) in protecting the cornea from endothelial cell loss during cataract surgery.

Methods: A systematic review yielded 21 randomized controlled trials including 1769 patients. OVDs were classified according to the Arshinoff classification. Traditional pairwise meta-analyses were performed for each direct comparison. Mixed treatments comparisons (MTC) analysis was performed additionally, to combine all direct and indirect comparisons. The outcome measure was loss in endothelial cell density three months after surgery.

Results: Direct comparison meta-analysis showed that viscoadaptives lead to a lower loss in cell density compared to very low viscosity dispersives, and compared to super viscous cohesives. The soft-shell technique, a combination of viscous cohesives and medium viscosity dispersives, shows a lower loss compared to viscous cohesives, but was not compared to the other treatments. The mixed treatment comparisons analysis shows that comparing all treatment options together, all mean differences are ≤100 cells/mm2. The probability of being the best treatment option is 80% for viscoadaptives and 18% for the soft shell technique.

Conclusion: Viscoadaptives may be superior to the other OVDs, but absolute differences in loss in endothelial cell density are <100 cells/mm2.

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