Eyeworld

60 | EYEWORLD | SPRING 2025 ATARACT C Relevant disclosures Al-Hashimi: None Chan: Théa Goyal: Alcon Contact Al-Hashimi: alhashimi@jsei.ucla.edu Chan: clarachanmd@gmail.com Goyal: himani.goyal.md@gmail.com Dr. Goyal said she also thinks there is value in using a smaller than standard speculum for patients with deep-set or smaller eyes. Making the patient more comfortable can affect how long the surgery takes and thus reduce the risk for an increase in postop edema. "Giving patients a little more anesthesia to keep them relaxed and from squeezing or baring down can affect the surgery," she said. Diagnosis Dr. Chan said anterior segment OCT is helpful to diagnose a Descemet's membrane detach- ment or retained lens fragment as the cause for prolonged corneal edema. Dr. Al-Hashimi said pachymetry can confirm the diagnosis of prolonged corneal edema, but he added that it's important to keep TASS in the differential if the edema is significant and there is a high degree of intraocular inflammation in the anterior chamber early on. Dr. Goyal said corneal edema is obvious when you see Descemet's folds associated with clouding of the stroma, but once the Descemet's folds resolve, reviewing the preop measure- ments and history and comparing to postop topography or pachymetry can help determine if there is persistent edema. Treatment Once it's clear the edema is not resolving, Dr. Al-Hashimi said the first thing is "don't panic." "Not uncommonly, corneal edema will resolve with time. Using a more frequent topical steroid regimen may help speed up recovery. It can take several weeks before corneal ede- ma fully resolves," he said. "It is best to follow patients with serial pachymetry to ensure the thickness continues to trend downward. This gives patients confidence that their situation is improving objectively even if their vision does not seem to be improving at first. If after 4 weeks you are no longer seeing progress, there is a high probability the patient will ultimately need an endothelial keratoplasty to resolve the issue. Sodium chloride ophthalmic solution drops or ointment can be used to help speed up recovery, but this typically is only useful when there is epithelial edema." Dr. Chan said treatment of the edema de- pends on its etiology and whether there was any pre-existing endothelial compromise or disease present. "If a retained nuclear cataract piece is re- moved within a week to a month, the cornea, if otherwise healthy, can typically clear up in 1–4 weeks," she said. "If a Descemet's membrane detachment is rebubbled within 1–3 weeks, [it] can usually have a clear cornea within a similar timeframe. Beyond a month the Descemet's membrane usually becomes fibrosed and can no longer contour against the stroma properly, and a DMEK may be needed. A history of HSV endothelial disease and/or iritis may also cause the endothelial cells to be dysfunctional or deficient, leading to a greater risk of prolonged corneal edema after cataract surgery, especial- ly if other intraoperative risk factors are not mitigated." Dr. Goyal said when there is no improve- ment of corneal edema or persistent edema at postop month 1, it's time to intervene. She starts treatment with sodium chloride drops or ointment. If this does not help, she would con- sider a rho-kinase (ROCK) inhibitor, which she said "can help our endothelial cells function at their best and are low risk." If a ROCK inhibitor is going to help, it would improve within a few days to weeks. If after that there is insufficient improvement, Dr. Goyal said it's time to consid- er an endothelial keratoplasty (DMEK), though she hopes in a few years endothelial cell thera- py could be an option. If there is long-standing corneal edema, especially in the setting of bullae and micro- cystic edema, Dr. Al-Hashimi said subepithelial scarring could develop, limiting vision even after a successful endothelial keratoplasty. "It is best to try addressing corneal edema with addi- tional surgery within a few months to minimize permanent scarring," he said. Dr. Chan said pa- tients could suffer pain from ruptured bullae or foreign body sensation from microcystic corneal edema that can occur with prolonged corneal edema. Dr. Chan said surgeons should carefully examine for post-cataract surgery corneal ede- ma. Always consider a Descemet's membrane detachment or retained nucleus piece as well because managing these problems as soon as possible can successfully reverse postoperative corneal edema. continued from page 59

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