Eyeworld

FALL 2024 | EYEWORLD | 65 C References 1. Das AV, Chaurasia S. Clinical profile and demographic distribution of Fuchs' endothelial dystrophy: An electronic medical record-driven big data analytics from an eye care network in India. Indian J Ophthalmol. 2022;70:2415–2420. 2. Vallabh NA, et al. Corneal endothelial cell loss in glaucoma and glaucoma surgery and the utility of management with De- scemet membrane endothelial keratoplasty (DMEK). J Ophthal- mol. 2022;2022:1315299. 3. Alfawaz AM, et al. Corneal endothelium in patients with anterior uveitis. Ophthalmology. 2016;123:1637–1645. 4. Kaup S, Pandey SK. Cataract surgery in patients with Fuchs' endothelial corneal dystro- phy. Community Eye Health. 2019;31:86–87. 5. Sharma N, et al. Corneal edema after phacoemulsifi- cation. Indian J Ophthalmol. 2017;65:1381–1389. 6. Antonini M, et al. Rho-associ- ated kinase inhibitor eye drops in challenging cataract surgery. Am J Ophthalmol Case Rep. 2021;25:101245. 7. Schoenberg ED, et al. Refractive outcomes of De- scemet membrane endothelial keratoplasty triple procedures (combined with cataract surgery). J Cataract Refract Surg. 2015;41:1182–1189. 8. Price MO, et al. Implanta- tion of presbyopia-correcting intraocular lenses staged after Descemet membrane endo- thelial keratoplasty in patients with Fuchs dystrophy. Cornea. 2020;39:732–735. 9. Price DA, et al. Initial results of DMEK combined with cataract surgery and implantation of the light-adjustable lens. J Cataract Refract Surg. 2024;50:270–275. of technology such as femtosecond lasers that may reduce phacoemulsification energy require- ments, increased use of mechanical chopping, or frequent reapplication of viscoelastic to protect the corneal endothelium from phacoemulsifica- tion energy." Dr. Price said one of the basic things physi- cians can do is manage viscoelastic. He prefers the softshell technique, where you lightly fill the anterior chamber with a dispersive viscoelastic. Then you go in with a little bit of cohesive vis- coelastic and put it on top of the lens, and that helps the iris not to prolapse during hydrodis- section and hydrodelineation, he said. If it's all dispersive, it can build up the pressure, and you could pop the iris out. The other thing you need to be careful with, Dr. Price said, are shallow anterior chambers because there's not as much working space. You want to carry out the surgery keeping the phaco as much as you can in the posterior chamber and not the anterior chamber, he said. With a dense nucleus requiring extra ener- gy, consider reapplying a dispersive viscoelastic a few times to protect the cornea, Dr. Price said. You might even want to consider a different approach to cataract surgery if the nucleus is dense. While not commonly done in the U.S., Dr. Price said, for a rock-hard cataract, you might consider using manual small incision sur- gery, which includes making a 7–8 mm incision and expressing the nucleus manually. After surgery, for those with endothelial damage and/or cell loss, Dr. Price said it's im- portant to treat the inflammation to try to mini- mize the amount of damage. At this point, there isn't anything to inject to help cells regenerate, but there are a number of medicines being looked at that may stimulate endothelial cells to recover better. Dr. Price said his course of action is to increase steroids to decrease inflammation in the eye and use hyperosmotics, like sodium chloride ointments and drops, to pull out excess fluid while the remaining endothelial cells cover areas that were damaged. We know from Descemet's stripping only (DSO) that you can remove central Descemet's membrane and endothelial cells, and peripher- al endothelial cells will migrate over time and cover the denuded area, he said. After cataract surgery, you'll see this around the wound, and those damaged areas usually clear up in days continued on page 66 The left panel shows a pseudophakic eye with Fuchs dystrophy prior to DMEK. The view of the IOL is obscured by the thickened Descemet's membrane and guttae. After removal of Descemet's membrane (right panel), it became obvious that the eye had a multifocal IOL. Source: Matt Feng, MD

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