Postoperative Corneal Edema
- Author: Michael Taravella, MD; Chief Editor: John D Sheppard, Jr, MD, MMSc more...
Pseudophakic bullous keratopathy (PBK) and aphakic bullous keratopathy (ABK) refer to the development of irreversible corneal edema as a complication of cataract surgery. As corneal edema progresses and worsens, first stromal and then intercellular epithelial edema develops. Epithelial edema is associated with the development of bullae; hence, the name bullous keratopathy. See the image below.
The history of PBK parallels the history of the development of the intraocular lens. As surgical techniques and lens design have improved, the incidence of this complication has decreased dramatically. However, it still represents an important cause of visual disability following routine and complicated cataract surgery.
Corneal transparency is, in a large part, dependent on the ability of the cornea to remain in a dehydrated state. It is affected by several interdependent factors. The epithelium and the endothelium are both semipermeable membranes that create a barrier to the flow of water and other electrolytes into the cornea. Evaporation from the corneal tear film results in slightly hypertonic tears that tend to draw fluid out of the cornea. Intraocular pressure tends to drive fluid into the cornea. Osmotic forces and the electrolyte balance within the corneal stroma also tend to draw water into the cornea. However, the most important influence on corneal deturgescence is the presence of an active metabolic pump in the endothelium.
The endothelium is a single layer of cells present on the back of the cornea. The site of the metabolic pump is within the lateral cell membrane; it is temperature dependent, it is associated with the enzyme Na+/K+ ATPase, and it is inhibited by ouabain. Endothelial cells produce a basement membrane (the Descemet membrane), and they are of neuroectodermal origin. Cell density at birth can be as high as 7500 cells/mm2, decreasing to an average of about 2500-2700 cells/mm2 in older adults.
Endothelial cells are not capable of significant mitotic activity. The normal rate of endothelial loss after age 20 years is approximately 0.5% per year. Surgical trauma, inflammation, and corneal dystrophies can accelerate this normal aging loss. The final common pathway in the development of bullous keratopathy is damage to the corneal endothelium; when the cell density reaches a critically low level of about 300-500 cells/mm2, corneal edema develops.
The exact incidence of PBK is unknown; however, it is estimated that 0.1% of patients undergoing cataract surgery will develop this problem.
The US Food and Drug Administration (FDA) premarket approval studies for intraocular lenses performed from 1978-1982 found an incidence of postoperative corneal edema of 0.06% for posterior chamber lenses, 1.2% for anterior chamber lenses, and 1.5% for iris fixated lenses.[3, 4, 5] Certain styles of intraocular lenses introduced in the mid 1980s were reported to have an incidence as high as 5% (eg, Leiske and Hessburg closed loop anterior chamber intraocular lenses, ORC Stableflex, Azar model 91Z).[6, 7] See the image below.
From 1984-1989, ABK and PBK accounted for most corneal transplants (about 33%) performed in the United States. Since then, the number of cases has decreased, despite an increase in the number of overall cataract surgeries performed. Keratoconus surpassed PBK in 1990 as the leading indication for corneal transplantation in some studies in the United States.[8, 9] This overall drop in the incidence of PBK reflects the rapid development and improvement of both intraocular lens design and cataract surgical technique.
Trends similar to that in the United States have been noted in Canada, United Kingdom, Australia, and Scandinavia.[10, 11, 12, 13]
No known association of PBK with race exists.
Patients of Northern European descent do have an increased incidence of Fuchs corneal dystrophy. This dystrophy does predispose to the development of corneal edema (see Pathophysiology, Causes, Histologic Findings).
No known association of PBK with sex exists.
Fuchs corneal dystrophy, a known predisposing factor in the development of postoperative corneal edema, occurs approximately 3 times more frequently in women than in men.
Older patients who have less endothelial reserve are more prone to develop this problem.
Claesson M, Armitage WJ, Stenevi U. Corneal oedema after cataract surgery: predisposing factors and corneal graft outcome. Acta Ophthalmol. 2009 Mar. 87(2):154-9. [Medline].
Smolin G, Thoft RA, Dohlman CH. Endothelial function. The Cornea: Scientific Foundations and Clinical Practice. 3rd ed. Lippincott William & Wilkins: 1994. 635-643.
Stark WJ, Worthen DM, Holladay JT, et al. The FDA report on intraocular lenses. Ophthalmology. 1983 Apr. 90(4):311-17. [Medline].
Taylor DM, Atlas BF, Romanchuk KG, Stern AL. Pseudophakic bullous keratopathy. Ophthalmology. 1983 Jan. 90(1):19-24. [Medline].
Waring GO 3rd. The 50-year epidemic of pseudophakic corneal edema. Arch Ophthalmol. 1989 May. 107(5):657-9. [Medline].
Archives of Ophthalmology. Closed-loop anterior chamber lenses. Arch Ophthalmol. 1987 Jan. 105(1):19-21. [Medline].
Hagan JC 3rd. A clinical review of the IOLAB Azar model 91Z flexible anterior chamber intraocular lens. Ophthalmic Surg. 1987 Apr. 18(4):258-61. [Medline].
Mamalis N, Anderson CW, Kreisler KR, Lundergan MK, Olson RJ. Changing trends in the indications for penetrating keratoplasty. Arch Ophthalmol. 1992 Oct. 110(10):1409-11. [Medline].
Kang PC, Klintworth GK, Kim T, Carlson AN, Adelman R, Stinnett S, et al. Trends in the indications for penetrating keratoplasty, 1980-2001. Cornea. 2005 Oct. 24(7):801-3. [Medline].
Liu E, Slomovic AR. Indications for penetrating keratoplasty in Canada, 1986-1995. Cornea. 1997 Jul. 16(4):414-9. [Medline].
Burdon MA, McDonnell P. A survey of corneal graft practice in the United Kingdom. Eye. 1995. 9 (Pt 6 Su):6-12. [Medline].
Williams KA, Muehlberg SM, Lewis RF, Coster DJ. How successful is corneal transplantation? A report from the Australian Corneal Graft Register. Eye. 1995. 9 (Pt 2):219-27. [Medline].
Haamann P, Jensen OM, Schmidt P. Changing indications for penetrating keratoplasty. Acta Ophthalmol (Copenh). 1994 Aug. 72(4):443-6. [Medline].
Morishige N, Chikama T, Yamada N, Takahashi N, Morita Y, Nishida T, et al. Effect of preoperative duration of stromal edema in bullous keratopathy on early visual acuity after endothelial keratoplasty. J Cataract Refract Surg. 2012 Feb. 38(2):303-8. [Medline].
Srinivasan S, Skarmoutsos P, O'Donnell C, Kaye SB. Localized bullous keratopathy secondary to posterior polymorphous dystrophy. Clin Experiment Ophthalmol. 2008 Nov. 36(8):800-1. [Medline].
Dick HB, Kohnen T, Jacobi FK, Jacobi KW. Long-term endothelial cell loss following phacoemulsification through a temporal clear corneal incision. J Cataract Refract Surg. 1996 Jan-Feb. 22(1):63-71. [Medline].
Hayashi K, Hayashi H, Nakao F, Hayashi F. Risk factors for corneal endothelial injury during phacoemulsification. J Cataract Refract Surg. 1996 Oct. 22(8):1079-84. [Medline].
Werblin TP. Long-term endothelial cell loss following phacoemulsification: model for evaluating endothelial damage after intraocular surgery. Refract Corneal Surg. 1993 Jan-Feb. 9(1):29-35. [Medline].
Hoffer KJ. Cell loss with superior and temporal incisions. J Cataract Refract Surg. 1994 May. 20(3):368. [Medline].
Lundberg B, Jonsson M, Behndig A. Postoperative corneal swelling correlates strongly to corneal endothelial cell loss after phacoemulsification cataract surgery. Am J Ophthalmol. 2005 Jun. 139(6):1035-41. [Medline].
Morikubo S, Takamura Y, Kubo E, Tsuzuki S, Akagi Y. Corneal changes after small-incision cataract surgery in patients with diabetes mellitus. Arch Ophthalmol. 2004 Jul. 122(7):966-9. [Medline].
Richard J, Hoffart L, Chavane F, Ridings B, Conrath J. Corneal endothelial cell loss after cataract extraction by using ultrasound phacoemulsification versus a fluid-based system. Cornea. 2008 Jan. 27(1):17-21. [Medline].
Storr-Paulsen A, Norregaard JC, Ahmed S, Storr-Paulsen T, Pedersen TH. Endothelial cell damage after cataract surgery: divide-and-conquer versus phaco-chop technique. J Cataract Refract Surg. 2008 Jun. 34(6):996-1000. [Medline].
Park J, Yum HR, Kim MS, Harrison AR, Kim EC. Comparison of phaco-chop, divide-and-conquer, and stop-and-chop phaco techniques in microincision coaxial cataract surgery. J Cataract Refract Surg. 2013 Oct. 39(10):1463-9. [Medline].
Abell RG, Kerr NM, Howie AR, Mustaffa Kamal MA, Allen PL, Vote BJ. Effect of femtosecond laser-assisted cataract surgery on the corneal endothelium. J Cataract Refract Surg. 2014 Nov. 40 (11):1777-83. [Medline].
Koch DD, Liu JF, Glasser DB, Merin LM, Haft E. A comparison of corneal endothelial changes after use of Healon or Viscoat during phacoemulsification. Am J Ophthalmol. 1993 Feb 15. 115(2):188-201. [Medline].
Lugo M, Cohen EJ, Eagle RC Jr, Parker AV, Laibson PR, Arentsen JJ. The incidence of preoperative endothelial dystrophy in pseudophakic bullous keratopathy. Ophthalmic Surg. 1988 Jan. 19(1):16-9. [Medline].
Adamis AP, Filatov V, Tripathi BJ, Tripathi RC. Fuchs' endothelial dystrophy of the cornea. Surv Ophthalmol. 1993 Sep-Oct. 38(2):149-68. [Medline].
Edelhauser HF, Van Horn DL, Hyndiuk RA, Schultz RO. Intraocular irrigating solutions. Their effect on the corneal endothelium. Arch Ophthalmol. 1975 Aug. 93(8):648-57. [Medline].
Edelhauser HF, Gonnering R, Van Horn DL. Intraocular irrigating solutions. A comparative study of BSS Plus and lactated Ringer's solution. Arch Ophthalmol. 1978 Mar. 96(3):516-20. [Medline].
Olson RJ, Kolodner H, Riddle P, Escapini H Jr. Commonly used intraocular medications and the corneal endothelium. Arch Ophthalmol. 1980 Dec. 98(12):2224-6. [Medline].
Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg. 2006 Feb. 32(2):324-33. [Medline].
Homer PI, Peyman GA, Sugar J. Automated vitrectomy in eyes with vitreocorneal touch associated with corneal dysfunction. Am J Ophthalmol. 1980 Apr. 89(4):500-6. [Medline].
Liu GJ, Okisaka S, Mizukawa A, Momose A. Histopathological study of pseudophakic bullous keratopathy developing after anterior chamber of iris-supported intraocular lens implantation. Jpn J Ophthalmol. 1993. 37(4):414-25. [Medline].
Cormier G, Brunette I, Boisjoly HM, LeFrançois M, Shi ZH, Guertin MC. Anterior stromal punctures for bullous keratopathy. Arch Ophthalmol. 1996 Jun. 114(6):654-8. [Medline].
Brightbill FS. Penetrating keratoplasty for pseudophakic bullous keratopathy. Corneal Surgery: Theory, Technique and Tissue. Mosby Inc; 1992. 151-163.
Koenig SB, Schultz RO. Penetrating keratoplasty for pseudophakic bullous keratopathy after extracapsular cataract extraction. Am J Ophthalmol. 1988 Apr 15. 105(4):348-53. [Medline].
Brightbill FS. Lens replacement in pseudophakic bullous keratopathy: anterior chamber intraocular lenses. Corneal Surgery: Theory, Technique and Tissue. 2nd ed. Mosby Inc; 1992. 163-7.
Brightbill FS. Posterior chamber intraocular lenses-scleral fixated. Corneal Surgery: Theory, Technique and Tissue. 2nd ed. Mosby Inc; 1992. 171-176.
Donaldson KE, Gorscak JJ, Budenz DL, Feuer WJ, Benz MS, Forster RK. Anterior chamber and sutured posterior chamber intraocular lenses in eyes with poor capsular support. J Cataract Refract Surg. 2005 May. 31(5):903-9. [Medline].
Pande M, Noble BA. The role of intraocular lens exchange in the management of major implant-related complications. Eye. 1993. 7 (Pt 1):34-9. [Medline].
Agarwal A, Jacob S, Kumar DA, Agarwal A, Narasimhan S, Agarwal A. Handshake technique for glued intrascleral haptic fixation of a posterior chamber intraocular lens. J Cataract Refract Surg. 2013 Mar. 39(3):317-22. [Medline].
Weene LE. Flexible open-loop anterior chamber intraocular lens implants. Ophthalmology. 1993 Nov. 100(11):1636-9. [Medline].
Zaidman GW, Goldman S. A prospective study on the implantation of anterior chamber intraocular lenses during keratoplasty for pseudophakic and aphakic bullous keratopathy. Ophthalmology. 1990 Jun. 97(6):757-62. [Medline].
Donnenfeld ED, Ingraham HJ, Perry HD, Russell S, Foulks G. Soemmering's ring support for posterior chamber intraocular lens implantation during penetrating keratoplasty. Changing trends in bullous keratopathy. Ophthalmology. 1992 Aug. 99(8):1229-33. [Medline].
Bleckmann H, Kaczmarek U. Functional results of posterior chamber lens implantation with scleral fixation. J Cataract Refract Surg. 1994 May. 20(3):321-6. [Medline].
Terry MA, Ousley PJ. Replacing the endothelium without corneal surface incisions or sutures: the first United States clinical series using the deep lamellar endothelial keratoplasty procedure. Ophthalmology. 2003 Apr. 110(4):755-64; discussion 764. [Medline].
Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea. 2006 Sep. 25(8):886-9. [Medline].
Melles GR. Posterior lamellar keratoplasty: DLEK to DSEK to DMEK. Cornea. 2006 Sep. 25(8):879-81. [Medline].
Price MO, Price FW Jr. Descemet's stripping with endothelial keratoplasty: comparative outcomes with microkeratome-dissected and manually dissected donor tissue. Ophthalmology. 2006 Nov. 113(11):1936-42. [Medline].
Price MO, Price FW. Descemet's stripping endothelial keratoplasty. Curr Opin Ophthalmol. 2007 Jul. 18(4):290-4. [Medline].
Wandling GR Jr, Rauen MP, Goins KM, Kitzmann AS, Sutphin JE, Kwon YH, et al. Glaucoma therapy escalation in eyes with pseudophakic corneal edema after penetrating keratoplasty and Descemet's stripping automated endothelial keratoplasty. Int Ophthalmol. 2012 Jan 13. [Medline].
Price FW Jr, Price MO. Evolution of endothelial keratoplasty. Cornea. 2013 Nov. 32 Suppl 1:S28-32. [Medline].
Tenkman LR, Price FW, Price MO. Descemet membrane endothelial keratoplasty donor preparation: navigating challenges and improving efficiency. Cornea. 2014 Mar. 33(3):319-25. [Medline].
Terry MA, Saad HA, Shamie N, et al. Endothelial keratoplasty: the influence of insertion techniques and incision size on donor endothelial survival. Cornea. 2009 Jan. 28(1):24-31. [Medline].
Smolin G, Thoft RA, Dohlman CH. Corneal dystrophies and degenerations. The Cornea: Scientific Foundations and Clinical Practice. 3rd ed. Lippincott William & Wilkins: 1994. 520-522.
Gothard TW, Hardten DR, Lane SS, Doughman DJ, Krachmer JH, Holland EJ. Clinical findings in Brown-McLean syndrome. Am J Ophthalmol. 1993 Jun 15. 115(6):729-37. [Medline].