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Dr. Lalit Verma
Chairman, Scientific Committee - AIOS
 
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Author Topic: Query No: 1147 – Pseudophakic corneal edema  (Read 918 times)
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« on: August 08, 2011, 11:12:01 AM »

Dear all,
I operated a 60yr old female (no systemic history) on 21/7/2011 for cataract.  Surgery was uneventful and clean, no peroperative complication.  From the first postop day she is having significant stromal edema with Descemet’s folds.
Vision CF 1m
Digitally IOP normal
Fundus normal
I have started in addition to topical antibiotic and steroids
Hypersol-5 2 hourly
Hypersol-6 oint TID
Iotim (oral steroid and acetazolamide given for initial 5 days and then stopped)
Now even after 2weeks there is no improvement in edema.  Condition is same as before. {Because of significant edema, Descemet’s memb. status not much clear on SLE,  it appears attached}
What to do next?

Dr. Kirti Jain

Responses:

No:1


Dear Dr Kirti Jain,
I would examine her again after anesthetising her cornea and then applying a few drops of glycerol (30 ml bottles of oral glycerol is available). This will help reveal a detached Descemet’s membrane.

With best wishes,
Dr. Ramesh D

No:2


Dear Dr. Kirti,
DM folds if present the IOP should normally be low. If so, I do not understand the need for Timolol or Acetazolamide... rather than letting our experienced fingers do the tonometry, it would be a good idea to a Goldmann’s AT. Most of the times we do get mires, and even if distorted, we do get an idea about the pressures. Other options are Tonopen or NCT. But Knowing the IOP is important before starting anti glaucoma medications always. Secondly if the corneal condition is so morbid that vision is only 1 mt, I would personally not be sure about the posterior segment. Is there only anterior segment involvement or is there underlying vitritis, is what needs to be seen. May be a B scan USG to compare vitreous echoes bilaterally would shed some light on that matter. Also it would pick up whether there are any choroidal detachments. So the possible options become: If IOP is normal- TASS or Endophthalmitis and If IOP is not normal then the cause for either increased or decreased IOP needs to be assessed and treated. If it is TASS, they do reasonably well with continued steroids. About Descemet’s status, I am sure you would have realised something wrong in Descemet’s while operating itself. If you had a Descemet’s detachment intraop which was large, then a Descemetopexy with C3F8 would be a better plan. If no then I don’t think that Descemet’s is at fault. You have not mentioned what cataract surgery it was. Was it a SICS , Phaco (Scleral tunnel or Clear corneal) and how was the pupil when you examined.
 
Regards,
Dr. Nishant Radke

No:3

Dear Dr. Kirti Jain,
Nucleo- tunnel disproportion with forceful delivery of nucleus might be the cause. Nothing much at this stage can be done except continuing medication, wait and watch and hope for the best. Good Luck.

DR PARTHASARATHI ROY
HALDIA, WEST BENGAL.

No:4

Sir,
In one of my patient I felt the same problem. She was one of my employees, so my position was very awkward. After one week I decided to put air in AC and it was unbelievable that on the very next day the cornea became completely clear except few DM folds, vision improved drastically and the patient became so happy .I still couldn't understand how it happened.

Dr Renu
Bihar.

No:5


Dear Dr. Kirti,
The cause of the condition is Descemet's membrane detachment. As Dr.Renu has informed, the injection of air into acts as a tamponade and the detached Descemet’s membrane gets attached and with endothelium resuming its function, keeping the cornea dehydrated, the vision clears. This is a common complication of Phaco as phaco energy is blamed, it is central planar type. But in your case as Dr.Parthasarathy from WB says, it is the forceful nuclear delivery, which caused the DMD. Your management is appropriate except Hypersol In some cases it gets alright by itself after some time, 3-4 weeks.

Dr. Seshubabu

No:6

Although C3F8 is the classical descemetopexy gas, air is also known to be useful to the end.
There are at least 2 reasons I would recommend air first:
* Availability of C3F8 may be a problem for most people;
* The effectiveness of the tamponade depends first upon the location of the bubble and then only upon the tightness or duration of tamponade; even short duration of tamponade has been seen to be effective in clearing the problem, as early as 1 hour of lying supine on the OT table.....
If the location of the bubble is above DM, the issue can be compounded with multiple tears and adhesions, more so with a longer tamponade which the C3F8 gives! We routinely use air now, although we have used C3F8  in the past and are having good results.

Dr T Raveendra
Visakhapatnam.

No:7

Accidental stripping of the entire Descemet’s membrane has also occurred in few cases, mistaking it for anterior capsule. During the surgery one would not notice any difficulty. Better to take up the patient for endothelial graft.

Dr. Punith Kumar

Expert Comment:

Dear Dr. Kirti Jain,
Persisting stromal edema that starts immediately after cataract surgery is most commonly due to intra-operative insult to the endothelium, either mechanical (eg. Difficult SICS/ECCE or phacoemulsfication surgery) or chemical (Toxic Anterior Segment Syndrome - TASS). Rarely Descemet’s detachment could also result in segmental or diffuse corneal edema.  The stromal edema of descemet's detachment is very profound and shows area of criss-cross clearing within the ground glass haze (somewhat like crocodile shagreen). Descemet's folds will obviously not be seen attached to the cornea and on careful slit lamp examination in high magnification one can usually visualize the detached Descemet’s membrane, seen as a fine glassy membrane which usually reattaches with the cornea at some peripheral point. If there is doubt of detached Descemet’s, a very useful investigation is spectral OCT of the cornea which will clearly show the presence and extent of detached Descemet’s membrane. If present, intracameral injection of 14%C3F8 or 20% SF6 will reattach the Descemet’s and clear the cornea dramatically.  Edema due to endothelial injury from mechanical causes will usually recover in most cases over 4-6 weeks. However severe endothelial injury such as after TASS may result in permanent endothelial decompensation and this can only be treated by an endothelial transplant.   In your case, it seems that the corneal edema is consequent to some form of intra-operative endothelial insult. Anti-glaucoma medication will not help unless there is concomitant ocular hypertension. Hypersol is useful only if there is epithelial edema/bullae. It has no role in isolated stromal edema. The patient will require a higher dose of topical steroid with slow tapering. If the corneal stromal edema persists after 4-6 weeks, then I would suggest you refer your case to a cornea specialist to consider DSEK (Descemet's Stripping Endothelial Keratoplasty)

Regards,
Dr. Rishi Swarup
« Last Edit: November 19, 2011, 12:43:27 PM by admin » Logged
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