Corneal decompensation after cataract surgery can occur in patients with Fuchs' endothelial dystrophy. This paper reviews the pathogenesis of corneal edema in Fuchs' dystrophy, the preoperative and perioperative risk factors for corneal endothelial cell loss during cataract surgery, and indications for cataract surgery alone or cataract surgery combined with keratoplasty for patients with visually significant cataracts and Fuchs' dystrophy.
Accelerated loss of corneal endothelial cells in Fuchs' dystrophy is multifactorial, with apoptosis and altered gene regulation of aquaporin proteins playing a role. Preoperative factors contributing to decreased endothelial cell count include age, sex, diabetes, a history of ocular trauma or inflammation, and contact lens wear. Intra-operative measures shown to protect endothelial cells include the use of the soft-shell viscoelastic technique for very dense cataracts, efficient cataract removal techniques (phaco-chop, use of oscillatory handpiece), and surgery by an experienced surgeon. A triple procedure should be performed with preoperative corneal epithelial decompensation and considered with preoperative pachymetry greater than 640 mum. Otherwise, it is reasonable to attempt cataract surgery alone with proper patient education.
Fuchs' dystrophy is a progressive disorder. Cataract surgery in the setting of Fuchs' dystrophy can be performed successfully, especially when the surgeon is aware of the preoperative and intraoperative factors that affect the number of functioning endothelial cells. All patients should be aware of the progressive nature of this disease and the possibility of keratoplasty at some point in their lifetime.
"Whenever cataracts that disturb vision develop in FCD patients with moderate-to-low ECC densities, ophthalmologists have to decide whether cataract surgery should be immediately performed or postponed until keratoplasty is required. The better option for visual rehabilitation in FCD patients has long been controversial; it is unclear whether cataract surgery alone or cataract surgery combined with keratoplasty should be performed [18-20]. Our data indicated how fast the natural course of ECC changes progress in FCD patients with the intervention of cataract surgery. "
[Show abstract][Hide abstract] ABSTRACT: To evaluate the natural course of the long-term endothelial cell changes in Fuchs corneal dystrophy (FCD) patients and investigate the effects of phacoemulsification on the annual rate of change in endothelial indices in FCD patients.
Thirty-four patients diagnosed with FCD at Seoul National University Hospital from 1994 to 2010 were retrospectively reviewed. Sixteen patients who had been followed up for more than 1 year were selected and classified into 3 groups: group A, patients with no ocular surgery; group B, patients who had undergone phacoemulsification only; and group C, patients who had undergone penetrating keratoplasty with cataract surgery. Endothelial cell density, polymegethism, pleomorphism, and pachymetry were measured and the exponential rates of endothelial cell and pachymetry change were analyzed.
A non-linear mixed model of non-operated FCD patients showed that only pachymetric data tended to increase with statistical significance (p = 0.001) with a mean follow-up period of 4.15 years. Using an exponential regression analysis fitting curve, the mean rates of annual endothelial cell loss were 0.82%/yr, 20.39%/yr, and 29.27%/yr in groups A, B, and C respectively, and statistical significance was seen only in group C (p < 0.05).
Retrospective long-term follow-up data showed that changes in endothelial density did not significantly decrease over at least 4 years in middle-aged FCD patients. The changes in pachymetric corneal thickness appeared to increase over the same period. Considering that no exponential changes were aggravated after performing cataract surgery alone, cataract surgery would be a preferable option in FCD patients compared to an approach of "wait-and-do" penetrating keratoplasty combined with cataract surgery.
Korean Journal of Ophthalmology 12/2013; 27(6):409-15. DOI:10.3341/kjo.2013.27.6.409
[Show abstract][Hide abstract] ABSTRACT: Pseudophakic bullous keratopathy (PBK) is one of the main indications for corneal transplantation. Graft survival and visual outcome in this group are often poorer than for other indications. The aim of this study was to find risk factors for developing corneal oedema after cataract surgery and factors that influence the subsequent survival of the graft and the visual outcome.
We carried out an observational, retrospective cohort study using data from the Swedish Cornea Transplant Register and patient medical records. A total of 273 patients whose indication for corneal transplantation was corneal oedema after cataract surgery were included in the study. Multiple logistic regression analysis and, where appropriate, univariate analyses were applied.
A total of 43% of the patients developed persistent corneal oedema immediately after cataract surgery, the main risk factors for which were phacoemulsification and pre-existing endothelial disease. Almost a third (32%) of the transplants for PBK failed within 2 years, for which rejection and other postoperative complications increased the risk. Half (50%) the patients had visual acuity < or = 0.1 at 2 years after keratoplasty. Comorbidity, increasing duration of the bullous keratopathy and increasing age affected the visual outcome negatively.
Phacoemulsification was a risk factor for immediate persistent corneal oedema after cataract surgery, although it did not increase the overall risk of developing PBK. However, transplants for immediate PBK had a better survival rate than those for later onset PBK. Shorter duration of PBK and intraocular lens exchange at the time of penetrating keratoplasty increased the likelihood of good visual acuity.
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