Balanced versus hybrid phacoemulsification tips in grade 3 nuclear cataracts: a prospective randomized clinical study

To compare intraoperative efficiency and early postoperative corneal endothelial parameters between a balanced metal phacoemulsification tip and a hybrid polymer-coated tip. In this prospective randomized clinical study, patients with grade 3 nuclear cataract were assigned to phacoemulsification using either a balanced metal tip or a hybrid polymer-coated tip. The primary outcome was total ultrasound time, assessed within a noninferiority framework. Secondary outcomes included cumulative dissipated energy (CDE), average torsional amplitude, aspiration time, fluid usage, intraoperative complications, and endothelial parameters at postoperative day 7. A total of 470 eyes were analyzed (balanced, n = 236; hybrid, n = 234). The hybrid tip met the predefined noninferiority criterion for total ultrasound time (mean difference, hybrid minus balanced, − 10.18 s; 95% CI − 15.28 to − 5.09) and showed a shorter observed ultrasound time than the balanced tip (median, 43.9 vs. 58.8 s; p < 0.001). CDE and torsional amplitude were higher, whereas aspiration time and fluid usage were lower with the hybrid tip (all p < 0.001). Postoperative endothelial data were available for 375 eyes. At day 7, the hybrid group showed higher endothelial cell density, lower endothelial cell loss, and fewer eyes with > 10% endothelial loss. In eyes with grade 3 nuclear cataract, the hybrid polymer-coated tip was noninferior to the balanced metal tip for total ultrasound time. Although CDE was higher, the hybrid tip was associated with shorter ultrasound exposure, lower aspiration time and fluid usage, and a more favorable early endothelial profile.