EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
Issue link: https://digital.eyeworld.org/i/78788
28 EW CATARACT August 2012 Complicated cataract cases Cataract surgery in patients with Fuchs' dystrophy by Brian Alder, M.D., and Terry Kim, M.D. uchs' dystrophy is the most common endothelial dystrophy affecting human corneas. Cataract is the most common ailment affecting the eye of older adults. The intersection of these two problems in the same eye is not uncommon. Many patients with cataract have mild to F moderate guttata and stromal thickening at the time of cataract evaluation. In many cases it is not clear whether cataract or Fuchs' dystrophy contributes more to the decline in vision. Clinical judgment and experience are necessary to distinguish between the contri- butions. Sometimes it isn't known until after surgical intervention. In recent years, endothelial keratoplasty (DSAEK, DSEK, DMEK) replaced penetrating keratoplasty as the most common surgical procedure for treating advanced Fuchs' corneal endothelial dystrophy. Endothelial keratoplasty has significant advantages with respect to recovery time; reduced comorbidity, especially astigmatism; and easier decision- making with regard to combined surgery as compared to penetrating keratoplasty. Its dis- advantages are a hyperopic shift in post-op refraction if significant stromal tissue remains on the graft (DSAEK, DSEK) and a slightly reduced corrected visual acuity. The latter problem seems to have been resolved in large measure by eliminating most or all of the stromal tissue (DMEK). The fundamental decision that a cataract surgeon must make is whether to perform cataract surgery alone, endothelial kerato- plasty alone, or combined surgery. Simple metrics provide general guidelines but do not predict the behavior of every eye. Clinical fac- tors such as a history of early morning blurred vision and a finding of subtle Descemet's striae often influence the decision-making process, regardless of the numbers. Cataract surgery is safer than it used to be. Advanced phaco technologies, excellent dispersive and viscoadaptive OVDs, soft shell techniques, and advanced fluidics have low- ered the rate of endothelial cell injury and loss. Operating on patients with Fuchs' dystrophy is not as traumatic as it would have been just a few years ago. In this issue, Brian Alder, M.D., and Terry Kim, M.D., discuss the decision-making process for eyes with Fuchs' dystrophy. They also discuss intraoperative and post-op considerations when combined surgery is performed. Kevin Miller, M.D., Complicated cataract cases editor P atients with Fuchs' corneal endothelial dystrophy and cataract can present a unique challenge to the ophthal- mologist. While many such patients have a visually significant cataract and Fuchs' dystrophy and clearly re- quire combined cataract extraction with endothelial transplant, there are situations where one may pro- ceed with either cataract surgery or Descemet's stripping automated en- dothelial keratoplasty (DSAEK) sur- gery alone. Here we will present our views on clinical settings wherein cataract surgery may be performed without endothelial transplant, as well as focus on several surgical techniques that may aid in a suc- cessful outcome. Finally, we discuss several post-op recommendations specific to the patient with mild Fuchs' dystrophy who has under- gone cataract extraction. Decision-making: Cataract extraction alone or combined DSAEK surgery? Several factors must be considered when evaluating a patient with both cataract and Fuchs' dystrophy. A primary consideration for such pa- tients is the severity and degree of each disease process present. If a pa- tient has significant guttae on exam, documented increasing pachymetry or significant asymmetry on pachymetry, or any evidence of epithelial edema, we recommend proceeding with combined cataract extraction and endothelial trans- plant. In addition, if patients report a history of morning blurry vision that clears over the day, consistent with microcystic edema from Fuchs' dystrophy, despite a mild appear- ance on exam, strong consideration should be given to proceeding with a combined surgery. Another key consideration is the patient's visual demand. Recommen- dations may differ for the 55-year- old requiring a high degree of visual acuity for many years and the 90- year-old who would like to regain some reading vision. Similarly, one must consider a patient's ability to provide necessary post-op care for a transplant for an extended period of time compared to post-op cataract care. Figure 1. Patient with significant corneal endothelial guttae on slit lamp examination Figure 2. Patient with advanced Fuchs' dystrophy and endothelial cell loss on specular microscopy Figure 3. Example of chop technique and OZil torsional phacoemulsification (Alcon) settings to decrease corneal endothelial damage during cataract extraction Source (all): Brian Alder, M.D., and Terry Kim, M.D.