eMedicine Specialties > Ophthalmology > Cornea
Corneal Edema, Postoperative: Treatment & Medication
Updated: May 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
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.34 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.
Surgical Care
Definitive treatment of PBK and ABK is a corneal transplant.35,36 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.37,38,39,40
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.41,42 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.43
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.44
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.45,46,47,48,49
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.
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.50
Medication
The goal of pharmacotherapy is to reduce morbidity and to prevent complications.
Hypertonic solutions and ointments
Create an osmotic gradient, and draw fluid from the cornea.
Sodium chloride 2%, 5% (Muro 128, Adsorbonac) drops and ointment
For osmotic pressure control and water distribution.
Adult
1-2 gtt q1h into affected eye until noon (4-5 times); then, several times during the rest of the day prn
0.25 inch of ointment into affected eye hs
Pediatric
Administer as in adults
May decrease levels of lithium when administered concurrently
Fluid retention; hypernatremia; hypertonic uterus
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in congestive heart failure, hypertension, edema, liver cirrhosis, renal insufficiency, sodium toxicity
Antibiotics
Empiric antimicrobial therapy must be comprehensive, covering all likely pathogens in the context of the clinical setting.
Polymyxin/trimethoprim (Polytrim drops), (Polysporin ointment)
For ocular infections, involving cornea or conjunctiva, resulting from strains of microorganisms susceptible to this antibiotic. Available as a solution and ointment.
Adult
Solution: 1-2 gtt q2h in affected eye, while awake
Ointment: Apply 0.5-inch ribbon into conjunctival sac qid and/or hs
Pediatric
<2 months: Not established
> 2 months: Administer as in adults
None reported
Documented hypersensitivity; viral, fungal, and mycobacterial infections of the eye
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Do not use in deep ocular infections or in those likely to become systemic; prolonged use of antibiotics or repeated therapy may result in bacterial or fungal overgrowth of nonsusceptible organism
Corticosteroids
Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Prednisolone acetate (Pred Forte)
Treats acute inflammations following eye surgery or other types of insults to the eye.
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
Solution: 1-2 gtt into conjunctival sac q1h during day and q2h noct; once desired response is obtained, use 1 gtt q4h; may reduce to 1 gtt tid/qid to control symptoms
Suspension: Shake well before using and instill 1-2 gtt into conjunctival sac 2-4 times/d; if necessary, may increase dosing frequency during initial 24-48 h
Pediatric
Administer as in adults
Effects may decrease in patients taking phenytoin, barbiturates, and rifampin
Documented hypersensitivity; viral, fungal, or tubercular infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hypertension; known to cause cataract formation with chronic use; in prolonged use, withdraw treatment by gradually decreasing frequency of applications to avoid adrenal insufficiency; may increase IOP; prolonged use may result in glaucoma
Alpha 2-adrenergic agonists
Can decrease IOP.
Brimonidine (Alphagan)
Selective alpha 2-receptor that reduces aqueous humor formation and increases uveoscleral outflow.
Adult
1 gtt in affected eye tid
Pediatric
Not established
Coadministration with topical beta-blockers may further decrease IOP; tricyclic antidepressants may decrease effects of brimonidine; CNS depressants (eg, barbiturates, opiates, sedatives) may potentiate effects of brimonidine
Documented hypersensitivity; patients receiving MAOIs therapy
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May exacerbate or precipitate ocular irritation, topical sensitivity, vasovagal attack, and optic nerve ischemia in patients with advanced glaucomatous optic neuropathy. Agitation, apnea, bradycardia, convulsion, cyanosis, depression, dyspnea, hypotension, hypothermia, hypotonia, hypoventilation, lethargy, somnolence, and stupor have been reported in pediatric patients.
Beta-adrenergic blockers
These agents reduce elevated and normal IOP, with or without glaucoma.
Timolol (Timoptic, Blocadren)
May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor or by outflow.
Adult
1 gtt of 0.25% or 0.5% in affected eye(s) bid
Pediatric
Administer as in adults
May cause bradycardia and asystole when used in combination with systemic beta-blockers (may cause additive effects)
Documented hypersensitivity; bronchial asthma, sinus bradycardia, second- and third-degree AV block, severe COPD, overt cardiac failure, and cardiogenic shock
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Product may have sulfites, which may cause allergic-type reactions in susceptible patients; may exacerbate or precipitate heart block, asthma, COPD, mental changes (especially in elderly persons)
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
Keywords
postoperative corneal edema, pseudophakic bullous keratopathy, PBK, aphakic bullous keratopathy, ABK, pseudophakic corneal edema, aphakic corneal edema, corneal edema, bullous keratopathy, cataract surgery
