Postoperative Corneal Edema Treatment & Management

  • Author: Michael Taravella, MD; Chief Editor: Hampton Roy Sr, MD   more...
 
Updated: Feb 14, 2012
 

Medical Care

Medical therapy of PBK consists of attempting to minimize corneal edema and the associated symptoms of discomfort and poor vision. Patients with early mild corneal edema may benefit from the use of hypertonic agents, such as sodium chloride 2% and 5% solution and ointment. These agents work by creating a hypertonic tear film, drawing water out of the cornea. Because evaporation from the tear film is minimal at night with the eyes closed (therefore, the tears are less hypertonic), corneal edema tends to be worse in the morning. Use of hypertonic sodium chloride 5% ointment at night applied to the conjunctival cul-de-sac limits this build-up of edema. Use of hypertonic solutions in the morning also helps eliminate some of this nightly fluid accumulation.

A typical regimen is Muro 128 2-5% drops used hourly in the affected eye until noon (4-5 times). As the day progresses, evaporation from the tear film begins to create relative hypertonicity of the tears, drawing fluid from the cornea. This accounts for the typical history of improving vision toward the end of the day.

Other practical methods of limiting corneal edema in eyes with borderline endothelial function include treatment of both ocular inflammation and elevated intraocular pressure (see Pathophysiology, Causes) if present.

Bandage contact lenses may be useful as an adjunct to medical treatment for the temporary relief of corneal pain and discomfort. They act to shield the cornea and epithelium from the eyelid. In general, thin, high-water content lenses are tolerated best because they are more oxygen permeable. However, contact lens wear, especially overnight wear, can be associated with increased corneal edema due to improper fit (tight lens) and an increased risk of infection in an already compromised cornea. Patients for whom a bandage lens is prescribed should be treated with a broad-spectrum antibiotic (eg, Polytrim) or an aminoglycoside 2-4 times a day. These patients require close follow-up care. Long-term use of a bandage lens for the treatment of this condition is not advised.

Patients who have poor visual potential and severe pain sometimes can benefit from anterior stromal puncture.[36] A 25-gauge needle is used to place multiple small superficial punctures in the affected area of the cornea. The depth of the puncture site is just at or below the Bowman layer. The epithelium subsequently scars firmly over the treated area. This often results in resolution of bullae and pain relief. A bandage lens should be placed over the cornea for 1-2 weeks to allow the epithelium to adhere to the underlying cornea. Excimer laser phototherapeutic keratectomy also has been used to achieve this effect.

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Surgical Care

Definitive treatment of PBK and ABK is a corneal transplant.[37, 38] Corneal transplantation is indicated when vision is decreased significantly by corneal edema or when pain becomes intractable. Although a complete discussion of corneal transplantation is beyond the scope of this article, certain unique aspects of corneal transplantation in this setting should be emphasized. First, the size of the graft should be as large as practical without increasing the risk of placing the graft too close to the limbus, thereby increasing the risk of graft rejection. This generally means a donor graft size of 8.00-8.50 mm. Increasing the donor graft size means that more of the healthy endothelium is transplanted. In addition, grafts with higher initial cell counts, 2500-3000 cells/mm2, are desirable for the same reason.

Another important consideration is the management of a preexisting intraocular lens.[39, 40, 41, 42]

Closed-loop anterior chamber intraocular lenses and iris clip style lenses should be removed because of their high association with continued endothelial cell loss and the potential harm to the donor cornea. Special techniques have been devised to remove the often scarred and embedded haptics of closed-loop anterior chamber intraocular lenses with the goal of minimizing iris and angle trauma and associated bleeding.

In general, well-positioned and appropriately sized flexible haptic anterior and modern posterior chamber intraocular lenses can be safely left in the eye. If replacement is anticipated, 4 options are currently available to the surgeon. These options include the following: (1) using a modern flexible loop anterior chamber intraocular lens, (2) placing a posterior chamber lens in the ciliary sulcus, (3) suturing a posterior chamber lens to the iris, or (4) suturing a posterior chamber lens in the sulcus. Often, the presence of anterior and posterior synechiae and glaucoma helps to determine the choice. Implantation techniques begin with careful removal of any anterior displaced vitreous and an equally careful lysis of iris synechiae.

Flexible haptic anterior chamber lenses should be reserved for those eyes with minimal anterior segment pathology, less than 90° of angle synechiae, and well-controlled intraocular pressure.[43, 44] Determining the correct width to implant is essential in preventing complications, such as iris tuck and ovaling (too large), as well as spinning or displacement of the lens (too small). Generally, the width chosen should correspond to a measurement of the horizontal white-to-white corneal diameter plus 1 mm. If inspection of the ciliary sulcus through gentle retraction of the iris reveals an intact and adequate capsular rim, then a posterior chamber intraocular lens can be inserted in the sulcus without suturing the lens in place.[45]

Sutured-in intraocular lenses generally should be reserved for eyes with extensive anterior segment pathology, lack of iris support for an anterior chamber lens, or glaucoma in which any further compromise of the angle may be anticipated to worsen the control of intraocular pressure.[46]

These 2 techniques are comparable in terms of results. Suturing a lens to the iris is technically easier than suturing a lens in the sulcus and has the added advantage of putting the iris on stretch, which may help to limit synechiae formation. However, once sutured, the iris no longer can be dilated and the retina easily examined. Suturing a lens in the ciliary sulcus places the haptics and lens optic in the most physiologic position; however, this technique is associated with a risk of lens tilt, bleeding from the ciliary body and uvea, and increased surgical time.

Many different variations of this technique have evolved, and special intraocular lenses with eyelets placed on the haptics to aid suture placement are available. It is up to the individual practitioner to determine which of these lens implant options is most appropriate for a given patient; however, it is important to note that no study to date has clearly pointed to an advantage of one technique or style of intraocular lens replacement in terms of graft survival, vision, or development of secondary complications (eg, glaucoma).

A new development in cornea transplantation has been the advent of DSAEK (Descemet Stripping Automated Endothelial Keratoplasty). Melles, Terry, Price, and Gorovoy have all been significant contributors to the development and refinement of this technique of endothelial replacement.[47, 48, 49, 50, 51]

The surgery begins by stripping off and removing a sheet of the patient's central endothelium (Descemet stripping). A posterior lamellar disc is prepared by placing a donor cornea in an artificial anterior chamber and cutting it with a microkeratome (the automated part). The donor disc is folded and inserted into the eye, where it is subsequently deployed and pushed against the patient's cornea with an air bubble. The bubble is then removed after a few minutes, leaving the donor disc in place.[52]

Advantages over traditional keratoplasty include quicker visual recovery and a much smaller incision, with improved wound strength, comparable to that seen with small incision cataract surgery. The patient's own corneal curvature is maintained with less induction of astigmatism. Disadvantages include the potential for dislocation of the donor disc, a problem more frequently encountered during the surgeon's learning curve. Visual acuity can be reduced by the lamellar interface between the donor disc and the patient's posterior corneal stroma. It is also more difficult to deploy the donor cornea disc in the presence of a preexisting anterior chamber lens, since there is less room for the disc to unfold. Finally, the method of insertion can significantly damage the donor corneal endothelium, and the best technique for insertion remains a point of contention among surgeons.[53]

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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: Nothing to disclose.

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.

Specialty Editor Board

Richard W Allinson, MD  Associate Professor, Department of Ophthalmology, 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.

Simon K Law, MD, PharmD  Associate Professor of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

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.

Christopher J Rapuano, MD  Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director 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; RPS Ownership interest Other; EyeGate Pharma Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting; Merck Honoraria Speaking and teaching

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.

References

  1. Claesson M, Armitage WJ, Stenevi U. Corneal oedema after cataract surgery: predisposing factors and corneal graft outcome. Acta Ophthalmol. Mar 2009;87(2):154-9. [Medline].

  2. Smolin G, Thoft RA, Dohlman CH. Endothelial function. In: The Cornea: Scientific Foundations and Clinical Practice. 3rd ed. Lippincott William & Wilkins: 1994:635-643.

  3. Stark WJ, Worthen DM, Holladay JT, et al. The FDA report on intraocular lenses. Ophthalmology. Apr 1983;90(4):311-17. [Medline].

  4. Taylor DM, Atlas BF, Romanchuk KG, Stern AL. Pseudophakic bullous keratopathy. Ophthalmology. Jan 1983;90(1):19-24. [Medline].

  5. Waring GO 3rd. The 50-year epidemic of pseudophakic corneal edema. Arch Ophthalmol. May 1989;107(5):657-9. [Medline].

  6. Archives of Ophthalmology. Closed-loop anterior chamber lenses. Arch Ophthalmol. Jan 1987;105(1):19-21. [Medline].

  7. Hagan JC 3rd. A clinical review of the IOLAB Azar model 91Z flexible anterior chamber intraocular lens. Ophthalmic Surg. Apr 1987;18(4):258-61. [Medline].

  8. Mamalis N, Anderson CW, Kreisler KR, Lundergan MK, Olson RJ. Changing trends in the indications for penetrating keratoplasty. Arch Ophthalmol. Oct 1992;110(10):1409-11. [Medline].

  9. Liu E, Slomovic AR. Indications for penetrating keratoplasty in Canada, 1986-1995. Cornea. Jul 1997;16(4):414-9. [Medline].

  10. Burdon MA, McDonnell P. A survey of corneal graft practice in the United Kingdom. Eye. 1995;9 (Pt 6 Su):6-12. [Medline].

  11. 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].

  12. Haamann P, Jensen OM, Schmidt P. Changing indications for penetrating keratoplasty. Acta Ophthalmol (Copenh). Aug 1994;72(4):443-6. [Medline].

  13. 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. Feb 2012;38(2):303-8. [Medline].

  14. Desir J, Abramowicz M. Congenital hereditary endothelial dystrophy with progressive sensorineural deafness (Harboyan syndrome). Orphanet J Rare Dis. Oct 15 2008;3:28. [Medline].

  15. Srinivasan S, Skarmoutsos P, O'Donnell C, Kaye SB. Localized bullous keratopathy secondary to posterior polymorphous dystrophy. Clin Experiment Ophthalmol. Nov 2008;36(8):800-1. [Medline].

  16. 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. Jan-Feb 1996;22(1):63-71. [Medline].

  17. Hayashi K, Hayashi H, Nakao F, Hayashi F. Risk factors for corneal endothelial injury during phacoemulsification. J Cataract Refract Surg. Oct 1996;22(8):1079-84. [Medline].

  18. Werblin TP. Long-term endothelial cell loss following phacoemulsification: model for evaluating endothelial damage after intraocular surgery. Refract Corneal Surg. Jan-Feb 1993;9(1):29-35. [Medline].

  19. Hoffer KJ. Cell loss with superior and temporal incisions. J Cataract Refract Surg. May 1994;20(3):368. [Medline].

  20. Lundberg B, Jonsson M, Behndig A. Postoperative corneal swelling correlates strongly to corneal endothelial cell loss after phacoemulsification cataract surgery. Am J Ophthalmol. Jun 2005;139(6):1035-41. [Medline].

  21. Morikubo S, Takamura Y, Kubo E, Tsuzuki S, Akagi Y. Corneal changes after small-incision cataract surgery in patients with diabetes mellitus. Arch Ophthalmol. Jul 2004;122(7):966-9. [Medline].

  22. 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. Jan 2008;27(1):17-21. [Medline].

  23. 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. Jun 2008;34(6):996-1000. [Medline].

  24. 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. Feb 15 1993;115(2):188-201. [Medline].

  25. 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. Jan 1988;19(1):16-9. [Medline].

  26. Adamis AP, Filatov V, Tripathi BJ, Tripathi RC. Fuchs' endothelial dystrophy of the cornea. Surv Ophthalmol. Sep-Oct 1993;38(2):149-68. [Medline].

  27. Edelhauser HF, Van Horn DL, Hyndiuk RA, Schultz RO. Intraocular irrigating solutions. Their effect on the corneal endothelium. Arch Ophthalmol. Aug 1975;93(8):648-57. [Medline].

  28. Edelhauser HF, Gonnering R, Van Horn DL. Intraocular irrigating solutions. A comparative study of BSS Plus and lactated Ringer's solution. Arch Ophthalmol. Mar 1978;96(3):516-20. [Medline].

  29. Olson RJ, Kolodner H, Riddle P, Escapini H Jr. Commonly used intraocular medications and the corneal endothelium. Arch Ophthalmol. Dec 1980;98(12):2224-6. [Medline].

  30. Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic anterior segment syndrome. J Cataract Refract Surg. Feb 2006;32(2):324-33. [Medline].

  31. Kang HM, Park JW, Chung EJ. A retained lens fragment induced anterior uveitis and corneal edema 15 years after cataract surgery. Korean J Ophthalmol. Feb 2011;25(1):60-2. [Medline]. [Full Text].

  32. Homer PI, Peyman GA, Sugar J. Automated vitrectomy in eyes with vitreocorneal touch associated with corneal dysfunction. Am J Ophthalmol. Apr 1980;89(4):500-6. [Medline].

  33. Smolin G, Thoft RA, Dohlman CH. Corneal dystrophies and degenerations. In: The Cornea: Scientific Foundations and Clinical Practice. 3rd ed. Lippincott William & Wilkins: 1994:520-522.

  34. Gothard TW, Hardten DR, Lane SS, Doughman DJ, Krachmer JH, Holland EJ. Clinical findings in Brown-McLean syndrome. Am J Ophthalmol. Jun 15 1993;115(6):729-37. [Medline].

  35. 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].

  36. Cormier G, Brunette I, Boisjoly HM, LeFrançois M, Shi ZH, Guertin MC. Anterior stromal punctures for bullous keratopathy. Arch Ophthalmol. Jun 1996;114(6):654-8. [Medline].

  37. Brightbill FS. Penetrating keratoplasty for pseudophakic bullous keratopathy. In: Corneal Surgery: Theory, Technique and Tissue. Mosby Inc; 1992:151-163.

  38. Koenig SB, Schultz RO. Penetrating keratoplasty for pseudophakic bullous keratopathy after extracapsular cataract extraction. Am J Ophthalmol. Apr 15 1988;105(4):348-53. [Medline].

  39. Brightbill FS. Lens replacement in pseudophakic bullous keratopathy: anterior chamber intraocular lenses. In: Corneal Surgery: Theory, Technique and Tissue. 2nd ed. Mosby Inc; 1992:163-7.

  40. Brightbill FS. Posterior chamber intraocular lenses-scleral fixated. In: Corneal Surgery: Theory, Technique and Tissue. 2nd ed. Mosby Inc; 1992:171-176.

  41. 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. May 2005;31(5):903-9. [Medline].

  42. 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].

  43. Weene LE. Flexible open-loop anterior chamber intraocular lens implants. Ophthalmology. Nov 1993;100(11):1636-9. [Medline].

  44. Zaidman GW, Goldman S. A prospective study on the implantation of anterior chamber intraocular lenses during keratoplasty for pseudophakic and aphakic bullous keratopathy. Ophthalmology. Jun 1990;97(6):757-62. [Medline].

  45. 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. Aug 1992;99(8):1229-33. [Medline].

  46. Bleckmann H, Kaczmarek U. Functional results of posterior chamber lens implantation with scleral fixation. J Cataract Refract Surg. May 1994;20(3):321-6. [Medline].

  47. 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. Apr 2003;110(4):755-64; discussion 764. [Medline].

  48. Gorovoy MS. Descemet-stripping automated endothelial keratoplasty. Cornea. Sep 2006;25(8):886-9. [Medline].

  49. Melles GR. Posterior lamellar keratoplasty: DLEK to DSEK to DMEK. Cornea. Sep 2006;25(8):879-81. [Medline].

  50. Price MO, Price FW Jr. Descemet's stripping with endothelial keratoplasty: comparative outcomes with microkeratome-dissected and manually dissected donor tissue. Ophthalmology. Nov 2006;113(11):1936-42. [Medline].

  51. Price MO, Price FW. Descemet's stripping endothelial keratoplasty. Curr Opin Ophthalmol. Jul 2007;18(4):290-4. [Medline].

  52. 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. Jan 13 2012;[Medline].

  53. Terry MA, Saad HA, Shamie N, et al. Endothelial keratoplasty: the influence of insertion techniques and incision size on donor endothelial survival. Cornea. Jan 2009;28(1):24-31. [Medline].

 
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Pseudophakic bullous keratopathy. Large multiple bullae, such as depicted here, are associated with moderate to severe pain and discomfort.
Pseudophakic bullous keratopathy in a patient with a Binkhorst style iris-fixated lens.
Pseudophakic bullous keratopathy. This patient has a closed-loop anterior chamber intraocular lens (Leiske model).
Specular microscopy of a normal cornea. Note the compact, uniform hexagonal appearance of the endothelial cells.
Specular microscopy illustrating moderate polymegathism and polymorphism. This is thought to be evidence of endothelial physiologic stress.
Fuchs endothelial dystrophy. The apparently empty spaces are occupied by guttate.
 
 
 
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