Cataract surgery in Fuchs' dystrophy
ABSTRACT 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.
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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.Acta ophthalmologica 07/2008; 87(2):154-9. DOI:10.1111/j.1755-3768.2008.01180.x · 2.51 Impact Factor
- Journal of Cataract and Refractive Surgery 07/2009; 35(7):1314–1315. DOI:10.1016/j.jcrs.2008.12.050 · 2.55 Impact Factor
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ABSTRACT: Patients with decreased vision due to Fuchs corneal dystrophy and cataract can present with a number of challenges to determine the best surgical option for restoring sight. The ophthalmologist must first distinguish how much of the vision loss is due to the cataract versus the Fuchs corneal dystrophy (FCD) before determining the best surgical course, either cataract surgery alone or cataract surgery combined with full thickness or lamellar keratoplasty. This review will discuss the various techniques and clinical signs to ascertain the source of vision loss and how to use this clinical information to help guide the surgical decision making process in order to optimize the best possible outcome. Over the last several years, the technique of endothelial keratoplasty has evolved to become an important alternative in the treatment of FCD. Anticipating the correct intraocular lens power for a patient undergoing cataract surgery alone followed by Descemet stripping endothelial keratoplasty (DSEK) or combined cataract surgery with DSEK requires understanding the hyperopic shift that can occur with DSEK and incorporating this correction preoperatively in the intraocular lens power selection. New developments in the surgical treatment of Fuchs corneal dystrophy have greatly enhanced our ability to restore vision and reduce the dependence on contact lenses in this genetic disease.Current opinion in ophthalmology 11/2009; 21(1):15-9. DOI:10.1097/ICU.0b013e328333e9d6 · 2.64 Impact Factor