Eyeworld

58 | EYEWORLD | SPRING 2025 ATARACT C by Liz Hillman Editorial Co-Director About the physicians Saba Al-Hashimi, MD Associate Professor of Ophthalmology University of California, Los Angeles Los Angeles, California Clara Chan, MD Associate Professor of Ophthalmology University of Toronto Toronto, Canada Himani Goyal, MD Clinical Associate Professor NYU Langone Health New York, New York C orneal edema after cataract surgery, or any intraocular surgery, is expected to an extent. Saba Al-Hashimi, MD, said swelling even out to week 2 postop is typical for cataract surgery. But as postop recovery stretches to 1 month or beyond, questions start rolling through the surgeon's mind, and they begin to treat the situation differently: Did I miss Fuchs dystrophy? Is this a Descemet's separation? Was too much energy used? What's next? Preop contributors There are several risk factors that put a patient at higher risk for prolonged corneal edema after cataract surgery. The most obvious, said Clara Chan, MD, is Fuchs dystrophy, with or without guttae. She also said any history of HSV could contribute as well. "If patients have a known disease, we can counsel them: 'There is a decrease in the health or number of endothelial cells in your cornea. These are the cells that pump out water from the cornea and help keep it clear. … We expect some corneal swelling normally, but you may have more because of this,'" said Himani Goyal, MD. "Without regularly getting a specular microscopy preoperatively, this can easily be missed," Dr. Al-Hashimi said of low endothelial counts that can be present without guttae. "If, however, the first eye ends up with more cor- neal edema than anticipated, it may be wise to obtain a specular microscopy before surgery on the second eye." Other risk factors, according to Dr. Chan, Dr. Al-Hashimi, and Dr. Goyal, include a dense arcus (which could put the patient at risk for retained nuclear fragments), small pupils (which might require expansion devices and more manipulation in the eye), dense cataracts (which could require more phaco energy), narrow angles, shorter anterior chamber depth (which puts you closer to the endothelium during surgery), and older age (which could make Descemet's detachment more likely). Dr. Goyal pointed out that patients with shallow chambers or endothelial disease might be more prone to iatrogenic Descemet's tears. These tears, she said, are common in the area of the main wound. They often flap back up and are of no consequence, but if they occur, they can prolong edema. Prevention While you can't change the anatomy of a small eye or dense lens, Dr. Al-Hashimi said some protective measures include use of a dispersive viscoelastic and keeping the phaco tip closer to the iris plane. "Additionally, the use of a femtosecond laser can help fragment the nucleus, and chopping techniques can also be used to reduce the cu- mulative dissipated energy from the phaco tip, which can also reduce the chances of develop- ing edema," he said. Overall tips Dr. Al-Hashimi provided were: with very dense cataracts, refill with OVD multi- ple times during the case ("the rule of thumb is to refill after each quadrant is removed"); aspi- rate some hyperthermic OVD over the cataract before using high phaco energy for sculpting; use care with wound construction to avoid a jagged internal main wound, which increases the risk for Descemet's detachment; ensure sufficient flow using phaco machine settings, and don't crimp the phaco needle sleeve; angle the phaco tip down and keep the eye parallel to the ground; take time out prior to IOL inser- tion to ensure it's the right IOL; avoid PCR by not over-hydrating dense lenses; and hydrate wounds gently at a physiologic IOP to lower Descemet's detachment risk. "Longer operating times are associated with corneal edema. In cases where there is a complication or the cataract surgery is more complex, the chances of seeing corneal edema postoperatively are increased," Dr. Al-Hashimi said. "Intraoperatively, using a dispersive visco- elastic (and replenishing as needed) can help protect the endothelium. If you see bubbles in the anterior chamber that are freely mobile in- stead of fixed in place, it can be a sign that the dispersive viscoelastic you used may no longer be adequately present in the eye; this is a good signal to stop and replenish if the patient has risk factors for developing edema." In smaller chambers, Dr. Goyal said to consider doing a pars plana vitrectomy to help deepen the chamber if you are comfortable with this technique, or use preop mannitol to shrink The conundrum of prolonged post-cataract corneal edema

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