# An Alternative Approach to Cataract Surgery Using BSS Temperature of 2.7 \({}^{\circ}\)C
## 4 Conclusions  
It is well known that the application of ultrasound during phacoemulsification can lead to endothelial cell damage in cataract surgery due to mechanical trauma from sonic waves and thermal injury [23]. In this scenario, our study demonstrated that the use of a cold irrigation solution plays a pivotal role in reducing or even preventing the damage of corneal endothelial cells during phacoemulsification.  
A presurgery test conducted on an artificial eye model allowed us to set the parameters to be used during cataract surgery, to ensure that there was no potential risk for the patients.  
In the preoperative period, the two groups of patients did not present statistically significant differences in numbers of endothelial cells. In the postoperative period a clear reduction, i.e., \(\sim\)50 % of endothelial cells in group A with respect to those in group B (\(p<0.001\)) was found.  
We also evaluated subgroups in relation to the AVG and found that there were no significant differences in the softer cataracts, which required an ultrasound percentage of less than 10% of the maximum power. Of note is the data showing a greater reduction in subjects in group B with medium  
\begin{table}
\begin{tabular}{c c c c c} \hline \hline \multirow{2}{*}{**AVG**} & \multirow{2}{*}{**Treatment**} & **Group A** & **Group B** & \multirow{2}{*}{_p-Value_} \\  & & **Mean \(\pm\) SD** & **Mean \(\pm\) SD** & **(Student’s Unpaired t-Test)** \\ \hline \multirow{2}{*}{0–9} & PRE & 2316.2 \(\pm\) 255.37 & 2312.08 \(\pm\) 313.02 & 0.95 \\ \cline{2-5}  & POST & 2050.31 \(\pm\) 240.56  & 2139.65 \(\pm\) 290.43  & 0.18 \\ \hline \multirow{2}{*}{10–19} & PRE & 2275.45 \(\pm\) 221.15 & 2368.87 \(\pm\) 333.57 & 0.1 \\ \cline{2-5}  & POST & 1830.79 \(\pm\) 210.55  & 2141.3 \(\pm\) 295.09  & \(<\)0.001  \\ \hline \multirow{2}{*}{20–29} & PRE & 2297.15 \(\pm\) 221.47 & 2392.35 \(\pm\) 261.01 & 0.24 \\ \cline{2-5}  & POST & 1528.62 \(\pm\) 132.56  & 2081.96 \(\pm\) 242.  
and hard cataract using ultrasounds higher than 10%, among whom we did not observe large losses of endothelial cells compared to those in group A, despite the high percentage of ultrasound used.  
For these reasons, and considering the protective role of BSS at low temperature (\(2.7\pm 0.1\)\({}^{\circ}\)C), we propose the use of this new technique mainly in medium and hard cataracts and in subjects at risk of corneal decompression.  
Despite these encouraging results, further studies are needed to establish the optimal BSS temperature at which the maximum anti-inflammatory effect can be achieved without causing cold damage. The reproducibility and relatively low cost of the method facilitate its widespread use.  
Conceptualization, A.M and G.A.; methodology, A.M., G.A., S.S.; validation, F.C., G.A.; formal analysis, L.B., S.G.; investigation, A.M., P.A., S.S.; resources, A.M., P.A., S.S.; data curation, B.T.; writing--original draft preparation, F.C., G.A.; writing--review and editing, F.C., G.A., S.G.; supervision, P.A.; All authors have read and agreed to the published version of the manuscript.  
This research received no external funding.  
The authors declare no conflict of interest.