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Objective  To compare the efficacy and safety of the intraocular lens (IOL)-shell procedure versus conventional phacoemulsification for the surgical treatment of dense cataracts.    Methods  Eighty eyes with dense nuclear cataracts were enrolled in a prospective, randomized controlled study. Patients were assigned to two groups. In Group I, the IOL was traditionally implanted after all nuclear fragments were completely removed, and in Group II, the IOL was innovatively implanted in the bag before the last residual nuclear fragment was removed. This novel adjusted surgical procedure, named the “IOL-shell technique”, features use of the IOL as a protective barrier rather than simply as a refractive alternative, and it is conceptually different from the traditional step-by-step procedure. Clinical examinations, including uncorrected visual acuity, central corneal thickness (CCT), temporal clear corneal incision thickness and corneal endothelial cell density, were carried out.    Results  The inter-group difference in temporal corneal thickness was found to be of no statistical significance at any of the visits. Compared to eyes in Group I, those in Group II were shown to have significantly less corneal endothelial cell loss on both the 7th and 30th day following surgery. At 7 days after surgery, the mean corneal endothelial cell loss in Group II was 10.29%, compared to 14.37% in Group I (P<0.05). The mean endothelial cell loss measured on postoperative day 30 was 16.88% in Group II compared to 23.32% in Group I (P<0.05). On the 1st day after surgery, the mean CCT of eyes in Group II was significantly smaller compared to Group I (Group I vs. Group II: 19.42% vs. 13.50%, P<0.05).    Conclusions  Compared to conventional phacoemulsification, the IOL-shell technique was shown to be a relatively safer procedure without compromised efficiency for dense cataracts, and it caused less corneal endothelial cell loss and milder postoperative corneal edema (Clinical Trials Identifier: NCT02138123).    Trial Registration    ClinicalTrials.gov NCT02138123

Intraocular Lens-Shell Technique: Adjustment of the Surgical Procedure Leads to Greater Safety When Treating Dense Nuclear Cataracts