Postoperative Corneal Edema Treatment & Management
- Author: Michael Taravella, MD; Chief Editor: John D Sheppard, Jr, MD, MMSc more...
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, thereby 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. Some clinicians even recommend a gentle hair dryer to the cornea in the morning to accelerate corneal deturgescence and therefore improved vision.
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, Azasite) 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. 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 has also been used to achieve this effect, as has epithelial debridement or lamellar keratectomy.
Finally, amniotic membrane in the form of a free graft protected by a bandage CTL or a ring-mounted contact lens (ProKera, BioTissue) can provide adjunctive benefits through intrinsic wound healing and growth factors, as well as anticollagenolytic and antimicrobial properties.
Definitive treatment of PBK and ABK is a corneal transplant.[38, 39] 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.[40, 41, 42, 43]
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, 5 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. A fifth option is externalizing the haptics of a posterior chamber intraocular lens, inserting them under scleral flap into and scleral tunnel, and gluing the flap over the haptic as described by Argawal et al. Often, the presence of anterior and posterior synechiae, iridodialysis, large peripheral or sector iridectomies, 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.[45, 46] 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.
Sutured-in intraocular lenses generally should be reserved for eyes with extensive anterior segment pathology, lack of iris support for an anterior chamber lens, lack of anterior capsular support for a sulcus lens, or glaucoma in which any further compromise of the angle may be anticipated to worsen the control of intraocular pressure.
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 open sky surgical time with its inherent increased risk of a choroidal effusion or hemorrhage. Externalizing the haptics of a 3-piece intraocular lens has gained popularity; however, this can be a time-consuming and difficult technique to master for novice surgeons.
Many different variations of these techniques 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 corneal transplant survival, vision, or development of secondary complications (eg, glaucoma).
A relatively new development in cornea transplantation has been the advent of DSAEK (Descemet Stripping Automated Endothelial Keratoplasty) and endothelial keratoplasty. Melles, Terry, Price, and Gorovoy have all been significant contributors to the development and refinement of this technique of endothelial replacement.[49, 50, 51, 52, 53]
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 elevated up against the patient's cornea with an air bubble. The bubble is then partially removed after a few minutes, leaving the donor disc in place.
A newer variation of endothelial keratoplasty is called Descemet membrane endothelial keratoplasty (DMEK). In this procedure, only Descemet membrane and endothelium from a donor is used to replace the recipient endothelium. DMEK offers quicker visual recovery, better best-corrected vision, and a decreased risk of rejection as opposed to Descemet stripping (automated) endothelial keratoplasty (DSAEK). However, the technique has not gained wide acceptance yet because of perceived difficulties in manipulating the Descemet membrane when it is separated from the overlying carrier disc of corneal tissue and increased risk of complications such as dislocation and tissue wastage.[55, 56] Furthermore, preparation of donor tissue for DMEK surgery is a challenging upgrade for eye banks.
Advantages of endothelial keratoplasty techniques over traditional keratoplasty include quicker visual recovery, preservation of the natural topography and prolate corneal contour, 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 preserved, 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 hazing or opacification of 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.
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].