eMedicine Specialties > Ophthalmology > Cornea

Dystrophy, Fuchs Endothelial: Follow-up

Author: Daljit Singh, MBBS, MS, DSc, Professor Emeritis, Department of Ophthalmology, Guru Nanak Dev University, Amritsar, India; Director, Daljit Singh Eye Hospital
Coauthor(s): Ravijit Singh, MD, Consulting Staff, Department of Ophthalmology, Daljit Singh Eye Hospital
Contributor Information and Disclosures

Updated: Feb 2, 2007

Follow-up

Further Inpatient Care

• If additional surgery is needed to treat various complications that can arise, further inpatient care may be required.

Further Outpatient Care

• Perform routine checkups to assess vision, fundus, and intraocular tension.
• Examine the condition of the graft every 15 days to look for a sign of graft rejection.
• Remove sutures at the following postoperative visits: interrupted sutures (starting 2-3 mo), running sutures (after 12 mo), and interrupted sutures (selectively remove until the astigmatism is less than 3 diopters).

Inpatient & Outpatient Medications

• Administer oral acetazolamide as needed to control IOP.
• Prednisolone acetate 1% drops instilled 8 times per day, tapering gradually to bid for 4-8 weeks and qd for several months. After this time, fluorometholone drops 0.25% are given for 1-2 years.
• If an epithelial defect is present, topical antibiotic drops or ointment are used 4-6 times per day.
• For patients with deficient tear secretion, use artificial tears 6-8 times per day.

Transfer

• Since the surgery is performed on elderly patients who are sometimes frail and who may have multiple health problems (eg, cardiovascular, respiratory, renal, cerebral systems), it is important to be prepared at all times to transfer the patient to an appropriate institution, as and when the need arises.

Deterrence/Prevention

• Protecting the eye
  • Patients should avoid rubbing and bumping the eye.
  • Patients should use a protective shield at night and protective glasses during the day for at least 3 months, and ideally longer, after surgery.
  • Patients should avoid splashing the eye with tap water when taking a bath.
• Patients should observe the following cleanliness guidelines:
• Avoid cleaning the eye with nonsterile products.
• Avoid applying cosmetics on the lid margin.
• Avoid smoke and dusty environment.
• Avoid putting any drops, other than prescribed drops, in the eye.
• Do not touch the nozzle of the eye drop bottle during use. Store the medicine bottle in a cool place, preferably inside a refrigerator.
• Patients should beware of warning signs; seek urgent consultation if any of the following warning signs occur:
  • Feeling of heaviness and pain
  • Redness of the eye, especially around the cornea
  • Diminution of eyesight
  • Light sensitivity

Complications

• Expulsive hemorrhage
• Wound separation and aqueous leakage
• Glaucoma
• Endophthalmitis
• Loose sutures, suture track infection
• Cataract formation
• Infective keratitis
• Epithelial healing problems and ulceration
• Graft rejection and failure
• Vitreoretinal problems - Cystoid macular edema, choroidal detachment, and retinal detachment

Prognosis

• As a result of a successful corneal graft, patients experience complete freedom from bullae formation, pain, and irritation.
• A high percentage of patients will have excellent transparency of the graft.
• If the host cornea is not vascularized, the chances of graft rejection are minimized.
• If the crystalline lens is transparent and the macular function is good, the chance of the patient regaining excellent vision is great.
• Secondary procedures may be necessary to minimize astigmatism and any gross refractive error.
• If the cornea has been vascularized as a result of repeated erosions and ulcer formation, the long-term results are less predictable.

Patient Education

• As long as the vision is good for practical purposes, with or without local medication, surgery is not needed.
• If a patient develops a cataract, that patient will need cataract surgery with or without keratoplasty. The surgeon in consultation with the patient will make the final decision.
• This corneal condition needs a long-term, close interaction between the patient and the ophthalmologist.
• The less affected eye needs as much attention as the affected eye.
• Since the condition can be familial, other members of the family should have an eye examination.
• A regular balanced diet and exercise are as useful to the body as they are to the eye.

Miscellaneous

Medicolegal Pitfalls

• Glaucoma diagnosed as Fuchs dystrophy, leaving glaucoma untreated
• Fuchs diagnosed as glaucoma, and unnecessary medication given or surgery performed
• Failure to diagnose and treat anterior segment inflammation causing corneal edema in a timely fashion
• Failure to perform a slit lamp examination/specular endothelial cell count prior to intraocular surgery (eg, cataract), especially in the presence of a history of corneal decompensation after surgery in the other eye
• Failure to take adequate precautions with viscoelastic materials, at the time of cataract surgery in a suspected case of Fuchs endothelial dystrophy
• Failure to warn the patient of the risk of corneal infection, when a bandage contact lens is advised for treating bullous keratopathy
• Failure to advise keratoplasty to treat corneal decompensation and other related problems

Special Concerns

• When beginning a slit lamp examination, specular endothelial microscopy should be habitual. In this way, cases with moderate or advanced cornea guttata will not escape detection.
• The age at which cataract surgery is required usually is when the patient already may have advanced cornea guttata. An undetected case may develop unforeseen severe endothelial damage during the course of cataract surgery. If the condition is diagnosed previously, special precautions may save the cornea.
• In case of glaucoma, examine the endothelium during the course of periodic follow-up care or prior to surgery.
• Any patient with unexplained corneal edema should get specular endothelial microscopy examination.
• Patients with bedewing of the epithelium or bullae formation need to be protected from infection. Patients who are using bandage contact lens should be advised to have their contact lens cleaned or changed at regular intervals. If the eye becomes red and painful or if the presence of a discharge is detected that was not seen previously, they should seek immediate expert aid. They also should report if a fall in the vision along with pain and redness occur.
• Patients of Fuchs endothelial dystrophy are usually older. General health care and cleanliness are important for the eye.

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