eMedicine Specialties > Ophthalmology > Cornea

Corneal Edema, Postoperative: Differential Diagnoses & Workup

Author: Michael Taravella, MD, Director of Cornea and Refractive Surgery, Rocky Mountain Lions Eye Institute; Professor, Department of Ophthalmology, University of Colorado School of Medicine
Coauthor(s): Mark Walker, MD, Medical Director, Laser Eye Connection
Contributor Information and Disclosures

Updated: May 11, 2009

Differential Diagnoses

Dystrophy, Fuchs Endothelial
Keratopathy, Pseudophakic Bullous
Posterior Polymorphous Corneal Dystrophy

Other Problems to Be Considered

Fuchs corneal dystrophy31
Iridocorneal endothelial syndrome
Brown-McLean syndrome32

Workup

Imaging Studies

  • Specular microscopy
    • Specular microscopy represents a photographic method of assessing the endothelium in vivo. Light is projected onto the cornea, and reflected images from an optical interface (eg, endothelium, aqueous humor) can be visualized.
    • High magnification photographs are taken of the endothelial layer, allowing quantification of cell density. Normal cell density varies from 3000-3500 cells/mm2 in young adults to 2000-2500 cells/mm2 in older individuals. Corneas with cell densities less than 1000 cells/mm2 are at moderate-to-high risk of developing corneal edema following intraocular surgery.
    • Instruments digitize and analyze these photographs, assessing such parameters as the coefficient of variation and the percent of hexagonal cells present. Both of these numbers represent a way of measuring polymorphism and polymegethism (ie, variation in cell size and shape) in the endothelial layer. Endothelial cells that show a great variability in size and shape are considered to be under physiologic stress and abnormal.
    • Besides evaluating the risk for the development of postoperative corneal edema, specular photomicrographs can be useful as a diagnostic aid to assess corneal disease states (eg, Fuchs corneal dystrophy, posterior polymorphous dystrophy). The former is associated with characteristic guttate excrescences, while the latter may show patchy areas of normal endothelium adjacent to abnormal endothelium, as well as vesicles and plaques. Serial specular photomicrographs can be used to follow patients at risk for progressive endothelial loss, such as that occurring with vitreous prolapse into the anterior chamber with corneal touch and corneal transplant rejection episodes.

      Specular microscopy of a normal cornea. Note the ...

      Specular microscopy of a normal cornea. Note the compact, uniform hexagonal appearance of the endothelial cells.

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      Specular microscopy of a normal cornea. Note the ...

      Specular microscopy of a normal cornea. Note the compact, uniform hexagonal appearance of the endothelial cells.


      Specular microscopy illustrating moderate polymeg...

      Specular microscopy illustrating moderate polymegathism and polymorphism. This is thought to be evidence of endothelial physiologic stress.

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      Specular microscopy illustrating moderate polymeg...

      Specular microscopy illustrating moderate polymegathism and polymorphism. This is thought to be evidence of endothelial physiologic stress.

Other Tests

  • Ultrasound pachymetry and optical pachymetry
    • Both ultrasound and optical pachymetry are methods of measuring corneal thickness. Normal corneal thickness measures about 0.55 mm centrally, increasing to about 0.8 mm in the corneal periphery. Disease states resulting in corneal edema are associated with central corneal thickening as the cornea begins to swell. Corneal thicknesses above 0.6 mm centrally are suspect for corneal edema (although a small number of normal subjects may have this thickness).
    • Serial measurements are helpful in gauging the progression of a disease process (eg, Fuchs dystrophy), as well as in assessing therapeutic regimens (eg, topical steroid use in corneal graft rejection).
    • Ultrasonic pachymetry is more reproducible and requires less skill than optical pachymetry; optical pachymetry is especially helpful in measuring the depth of cornea pathology (eg, scars, other lesions) when the full thickness of the corneal stroma is not involved and it is necessary for therapeutic reasons to estimate the depth of this pathology (preoperative for excimer laser phototherapeutic keratectomy).

Histologic Findings

Pathologic findings noted on corneas removed and replaced for PBK include attenuation and absence of normal endothelial cells.33 Occasionally, evidence of preexisting endothelial dystrophy (eg, Fuchs dystrophy) may be seen. This dystrophy sometimes is missed during the preoperative exam and, as such, is associated with the development of postoperative corneal edema. The hallmark of this dystrophy is the finding of corneal guttate (Latin for drop) excrescences and a thickened Descemet membrane. Cornea guttata appear as excrescences extending from the Descemet membrane toward the anterior chamber.

More on Corneal Edema, Postoperative

Overview: Corneal Edema, Postoperative
Differential Diagnoses & Workup: Corneal Edema, Postoperative
Treatment & Medication: Corneal Edema, Postoperative
Follow-up: Corneal Edema, Postoperative
Multimedia: Corneal Edema, Postoperative
References
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Further Reading

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Keywords

postoperative corneal edema, pseudophakic bullous keratopathy, PBK, aphakic bullous keratopathy, ABK, pseudophakic corneal edema, aphakic corneal edema, corneal edema, bullous keratopathy, cataract surgery

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Contributor Information and Disclosures

Author

Michael Taravella, MD, Director of Cornea and Refractive Surgery, Rocky Mountain Lions Eye Institute; Professor, Department of Ophthalmology, University of Colorado School of Medicine
Michael Taravella, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, and Eye Bank Association of America
Disclosure: Alcon Honoraria Speaking and teaching; Allergan Honoraria Speaking and teaching; Surgical Specialties Honoraria Speaking and teaching; BD Surgical Supplies Honoraria Speaking and teaching

Coauthor(s)

Mark Walker, MD, Medical Director, Laser Eye Connection
Mark Walker, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, and Contact Lens Association of Ophthalmologists
Disclosure: Nothing to disclose.

Medical Editor

Richard W Allinson, MD, Associate Professor, Department of Surgery, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic
Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Institute
Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery, and Pan-American Association of Ophthalmology
Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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