Postoperative Visual Clarity And Patient Satisfaction Depend On Corneal Clarity
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There is a wow effect from refractive cataract surgery because we can eliminate the lens opacity and address the astigmatism and spherical correction of the eye at the same sitting. This large improvement in vision is amazing, and as surgeons, we all know the joy of happy postoperative patients. However, the visual clarity after surgery depends on the corneal clarity, and any postop stromal edema will result in blurred vision during the initial healing period.
Uday Devgan
There are key steps to avoiding corneal edema after cataract surgery, which are well known by experienced surgeons. The general principle is to perform a gentler, less invasive and more efficient surgery, while returning the eye to its homeostasis balance by minimizing inflammation and pressure rises. These subtleties may not be as obvious to younger or beginning surgeons, so it is worth reviewing them in detail.
When performing hydrodissection, a significant amount of the viscoelastic will egress from the phaco incision because it is being displaced by the injected balanced salt solution. Just before placing the phaco probe in the eye, we can recoat the corneal endothelium with an additional bolus of dispersive OVD . This will help to protect the central corneal zone, which is most critical for excellent postoperative vision.
Corneal Swelling After Cataract Surgery
One of the most frequently asked questions is whether it is normal to have corneal swelling after cataract surgery. First of all, cataract surgery helps you to improve your vision and you would not want blurred vision after surgery. However, it is so normal to have corneal swelling after cataract surgery. Normally these may take a few days and after a short time of blurred vision and swelling eyelid, your vision gets clear.
Cataract Surgery Is A Modern Medical Miracle Performed On 38 Million Americans Per Year The Vast Majority Enjoy Clear Vision Within Days Of The Procedure And The Complication Rate Is Extremely Low
The cornea is clear tissue that forms the front of the eye. The iris, or colored part of the eye, is behind the cornea. If you place a contact lens in your eye, it will sit on the cornea. The cornea is clear because water is continuously pumped out of the tissue into the interior of the eye. When any intraocular surgery is performed the tissue pump is briefly inhibited and water enters the cornea. This creates blurred vision.
It is quite normal for the cornea to be swollen for a few days after surgery causing blurred vision. From time to time the swelling will last weeks and weeks.
Increased corneal swelling and blurred vision are commonly associated with:
- Intense post-operative inflammation
- Weak tissue pump
You will be happy to know that most cases of corneal swelling after cataract surgery respond to time and eye drops. In rare instances persistent swelling will require the services of a corneal specialist and a possible corneal transplant.
If you have questions about this subject, please contact Dr. Wilmarth.
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Some Eye Floaters After Cataract Surgery May Be Pathological
Some eye floaters noticed after cataract surgery are not normal. There are two possibilities to explain them:
For the reasons mentioned above, it is important for the patient to immediately go back to the ophthalmologist to have an eye exam to find out the cause and source of the eye floaters.
The good news is that in most of such scenarios, the eye exam will not reveal anything serious.
Prompt Identification Of Corneal Edema After Cataract Surgery Needed For Quick Recovery
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KOLOA, Hawaii Causes of corneal edema after cataract surgery are varied and must be identified and eliminated quickly, according to a speaker here.
In general, when you have corneal edema after cataract surgery, eliminate the inciting cause, be it a fragment, dislocated lens or detachment. Treat these patients aggressively with steroids and keep in mind they may need corneal transplantation,Terry Kim, MD, said at Hawaiian Eye 2017.
Terry Kim
The two most common conditions that can cause corneal edema after cataract surgery are Fuchs dystrophy and retained lens fragments after surgery. Fuchs dystrophy can be treated with a phacoemulsification procedure alone or a Descemet’s stripping endothelial keratoplasty triple procedure, Kim said.
If a patient has no morning blurring of vision, just mild guttae or minimal edema, and the clinician is comfortable with the patients lens density, a phacoemulsification procedure alone is appropriate. If a patient has morning blurring of vision, signs of epithelial edema, significant guttae and other factors, then a DSEK triple procedure is appropriate, Kim said.
In a retrospective case series at the Duke Eye Center, Kim found 60% of patients with corneal edema have a retained lens fragment after cataract surgery, with 80% being diagnosed with a lens fragment 1 day after cataract surgery.
Reference:
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Diagnosis Of Corneal Edema
An ophthalmologist will conduct a complete eye exam and diagnostic tests to understand what is causing your symptoms.
As part of the exam, your doctor may use a slit lamp or ophthalmoscope to determine what is occurring in the cornea. An ultrasound may be part of the diagnostic testing.
To determine the thickness of your cornea, your doctor may conduct a process called optical pachymetry. This is an outpatient procedure to take detailed measurements of the endothelium.
Biochemical Alterations In Corneal Edema
The endothelial tight junctions on the lateral membranes function in a delicate balance of the biochemical microenvironment. Both calcium and adenosine are required for the barrier function of the endothelium. Paucity of calcium ion or antioxidant glutathione and adenosine contribute to corneal edema. The irrigating solutions or drugs used intraoperatively may be a source of insult to the pump functioning of the endothelium.
The differential distribution of molecular channels regulating water influx and efflux called aquaporins are implicated in affecting the water transport mechanisms within the cornea. AQP abnormalities have been found in Pseudophakic corneal edema corneas and Fuchs endothelial corneal dystrophy corneas .
The aforementioned mechanisms in addition to the altered level of integrins leads to upregulation of inflammatory chemical mediators such as insulin-like growth factor 1, transforming growth factor-beta, bone morphogenetic protein 4 , interleukin-1 leading to progressive loss of stromal keratocytes, and formation of a posterior collagenous layer. In these long-standing cases, the corneal epithelium accumulates anti-adhesive proteins with simultaneous loss of adhesive proteins leading to the formation of fluid-filled bullae.
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Healing Time And Recovery
Your recovery time depends on the severity of your corneal edema, and how its treated. Mild corneal edema might not cause any symptoms or require treatment.
If you have surgery to replace your entire cornea, it could take a year or longer to get your vision back fully. Because the new cornea could be irregularly shaped, you may need to wear glasses to achieve clear vision.
Healing is much faster after a DSEK procedure, which removes only part of your cornea.
Know How To Differentiate Between Conditions That May Arise After Extraction
Cataract surgery has become one of the most frequently performed and most successful surgical procedures, with overwhelmingly positive outcomes.1 While the complication rate after cataract surgery is relatively low, the sheer number of procedures coupled with a large group of comanaging optometrists merits a review of potential postoperative complications.1 Most postoperative problems may be adequately treated by the comanaging OD, though some may require referral back to the surgeon. Postoperative complications are best characterized by the timeframe when they occur and by frequency.
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Research Design And Subjects
The present study was a pre-posttest study design. Fifteen subjects who diagnosed with moderate-to-severe corneal edema at day 2 post cataract surgery and underwent trans-corneal oxygenation therapy were recruited. Moderate edema was defined as increased stromal thickness, less than ten folds in the Descemet’s membrane and hazy iris details. The edema was labeled as being severe if the iris details were not visible there were more than 10 folds in the Descemet’s membrane and a marked increase in the corneal thickness. The inclusion criteria in this study were post cataract surgery patients with phacoemulsification technique with less than 1h surgical time and corneal edema at time of follow up, endothelial corneal counts â¥2000 cells/mm2 and central corneal thickness â¥450 µm, do not have other causes of corneal edema, such as: uveitis, glaucoma, congenital eye disorders, other corneal disorders such as corneal dystrophy, do not suffer from systemic disorders such as diabetes mellitus and immune disorders, do not have eye trauma, willing to do trans-corneal oxygenation therapy, and willing to participate in research and approve research sheets. Exclusion criteria in this study were patients who received other intervention therapies during follow-up and whose tear specimens were damaged so that LDH levels cannot be measured.
What Causes Corneal Edema
The cornea is made up of layers of tissue that help focus light on the back of the eye to produce clear images. Along the inner surface of the cornea is a layer of cells called the endothelium. Its job is to pump out any fluid that collects inside the eye.
When endothelial cells are damaged, fluid can build up and cause the cornea to swell, clouding vision. Endothelial cells can never regenerate. Once theyre damaged, theyre gone for good.
Diseases that damage endothelial cells and can cause corneal edema include:
- Fuchs endothelial dystrophy is an inherited disease that gradually destroys endothelial cells.
- Endotheliitis is an immune response that leads to inflammation of the endothelium. Its caused by the herpes virus.
- Glaucoma is a disease in which pressure builds up inside the eye. The pressure can build to the point where it damages the optic nerve and, in some cases, lead to corneal edema. This is uncommon, however.
- Posterior polymorphous corneal dystrophy is a rare, inherited condition of the cornea.
- Chandlers syndrome is a rare disorder in which cells of the epithelium multiply too quickly.
The use of certain drugs can also increase your risk for corneal edema:
- benzalkonium chloride, a preservative used in many eye drops and anesthetic drugs
- chlorhexidine , an antiseptic used to disinfect the skin before surgery
- amantadine , a drug used to treat viruses and Parkinsons disease
Other symptoms of corneal edema include:
- haloes around lights
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Descemets Membrane Related Procedures
The DMEK approach was described by Melles, to overcome some of the disadvantages of the DSEK surgery described earlier. In this approach, a disc of donor DM and endothelium are carefully stripped – usually 8 to 8.5 mm in diameter. Although this process has a learning curve, various modifications have been described to increase the harvest rate. The original Melles technique described injecting this scroll of tissue into the AC, using either a glass or plastic injector and once in the eye, small jets of fluid and stroking maneuvers on the corneal surface are used to unfurl the tissue. Air is used judiciously to help in this process, and when the graft is completely unfolded, the AC is filled with air to attach the graft. Although the procedure has a steep learning curve, once mastered, it allows early and excellent visual recovery, as there is no stromal interface and thickness in the graft. Similarly, the lesser transfer of donor tissue results in a lower endothelial rejection rate.
Surgical Decision Making Timing And Approach
With amelioration of aggravating factors and adequate conservative therapy, if endothelial recovery is not noted after three months, surgical options may be considered. Once the decision to proceed with surgery has been made, in persistent loss of endothelial function after cataract surgery, it is better to operate sooner than later. Persistent corneal edema can result in limbal stem cell dysfunction, AC inflammation, further stress on the surviving endothelial cells, vascularization of the cornea, surface irregularity, scarring and fibrosis, and posterior segment changes including cystoid macular edema owing to the changes in the anterior segment.
The choice of surgery depends on the findings in the eye and the experience of the surgeon. In general, there has been a shift in approach to selective lamellar corneal replacement over penetrating keratoplasty for pseudophakic corneal edema. This shift is due to better intra- and post-operative safety and earlier visual rehabilitation from retention of the corneal surface contour, lack of suture related complications, and a lower rejection rate.
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Can Eye Floaters Make You Blind
Eye floaters usually are small in size and do not cause blindness. However, massive bleeding inside the eye, for example as a result of diabetic retinopathy, may cause cloudy vision or blindness.
So if you notice eye floaters after cataract surgery, dont be worried. Most likely they are not a sign of any disease or complication of cataract surgery. Presence of floaters in the other eye may guide your whether or not the floaters in the operated eye are normal.
As a general rule, you should be alarmed when you notice some other symptoms as well in the first few days after cataract surgery. If you notice any pain, redness of the eye or reduction in vision , you must visit your eye doctor and get your eye examined to clear the doubts.
Usefulness Of Gonioscopy To Investigate Cause Of Corneal Oedema After Cataract Surgery By Jack Bradbury Corrado Gizzi And Anant Sharma
A 72-year-old man with ocular hypertension presented three months after routine right phacoemulsification and toric intraocular lens implantation with a two-week history of an irritated right eye and a sudden deterioration in right vision. His preoperative spherical equivalence was emmetropia, and the nuclear cataract was moderately dense.
Figure 1: A = lens fragment seen through gonioscopy lens B = pachymetry reveals corneal oedema greatest inferiorly C = lens fragment seen on ultrasound scan.
Case
Ocular examination showed significant generalised corneal oedema of the right eye, with visual acuity reduced to 6/36 unaided from 6/7.5 postoperatively. On slit-lamp examination, the anterior chamber appeared deep and quiet. Intraocular pressure of the right eye was elevated but was normal for the left eye .
Gonioscopy revealed a small retained lens fragment inferiorly as a possible cause of this patients corneal oedema, consistent with the pachymetry which showed the inferior corneal oedema was greatest. He was initially given a short course of Virgan as viral endotheliitis was a differential diagnosis, and he was started on Maxidex drops hourly and Cosopt twice a day.
The fragment was planned to be removed surgically, but it resolved after three months of Maxidex drops. Maxidex was stopped and the patients oedema did not return. However, he remains on Cosopt to control his ocular hypertension.
Discussion
References
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The Natural History Of Corneal Edema
In the early stages of corneal edema, reduced vision is often related to an irregular corneal surface and can interfere significantly with daily activities. This impact on vision is often underestimated by quantitative visual acuity measurements in standard lighting conditions using high contrast charts, as in a refracting lane.
Initially, these patients often experience blurred vision on awakening, owing to the accumulation of fluid in the closed eye state during sleep. As the day progresses, clarity may improve due to the increase in surface evaporation and the massaging action of blinking. This unique history is, therefore, used as an early indicator of failing endothelial function.
As the condition worsens, epithelial edema results in the formation of blebs and bullae, which can rupture during blinks, exposing corneal nerves, resulting in episodes of distressing pain, tearing, blurred vision and redness.
Repeated episodes of epithelial loss can cause constant stimulation of the limbal stem cells and gradual loss of function leading to superficial corneal vascularization. Loss of stromal compactness from the edema and the recurrent inflammation can induce stromal vascularization, as well. Over time, pannus formation and subepithelial fibrosis result in a quiet corneal surface, with loss of vision.
Data Collection And Study Protocol
Tear sampling was performed before trans-corneal oxygenation therapy, using Schimer paper sterilely, from the inferior fornix of the conjunctiva. Data recording and tear sampling were carried out at D2 and D5 postoperatively before and after trans-corneal oxygenation therapy. The primary outcome was LDH concentration in tears, obtained from ELISA results done at the Laboratory of Biomolecular and Cell Biology, Faculty of Medicine, Universitas Gadjah Mada, Indonesia. Clinical outcomes were visual acuity and specular microscopy parameters such as: corneal endothelial density, CCT, and coefficient of variation corneal endothelial .
All patients received sodium hyaluronate eye drops for corneal edema despite their routines post-cataract eye drops. Transcorneal oxygenation therapy was done using 100% oxygen at a flow rate of 5 L/min for 30min with an eyeshield at postoperative D2 and D5. The shield was firmly taped over the eye with all holes were closed except 1 for inserting the oxygen cannula and another for the exit of oxygen to keep the condition normobaric. Oxygen for transcorneal delivery was humidified using a bottle humidifier filled with distilled water. Oxygen was bubbled through the water, and a relative humidity of 80% was achieved. Patients blinked normally under the shield while receiving transcorneal oxygen.
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