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Case study: Progressive corneal edema seen in cataract surgery patient
Corneal edema, measured with pachymetry, can be resolved with removal of retained anterior chamber nuclear fragment.
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 Michael Rosenberg |
As reported by Henick and colleagues in 1994, removal of retained anterior chamber nuclear fragments after cataract surgery can lead to visual and symptomatic improvement. As surgical techniques and the quality of phacoemulsification machines with small-incision surgery have improved, small chips of nucleus occasionally hidden in the angle or behind the iris may go unnoticed. The amount of postoperative inflammation is greater with nuclear than cortical fragments, which often do not require intervention other than topical corticosteroid treatment. Risk factors include increased myopia, axial length and steep keratometry readings. Indications for removal include chronic inflammation, increased IOP and corneal decompensation. Small particles can resolve without intervention other than topical corticosteroid drops.
I monitored the postoperative resolution of corneal edema with serial pachymetry as a piece of retained nucleus was removed from a patient with an intact posterior capsule.
An 83-year-old Caucasian female patient on whose right eye I had performed cataract surgery complained of decreased vision in her left eye. Uncorrected vision in the left eye was 20/100. A manifest refraction in the left eye of –2.25 sphere produced 20/50 vision. Keratometry in the left eye was 41/50/42.75 with an axial length of 23.9 mm. Examination of the left eye was normal, excluding a moderate nuclear sclerotic cataract.
She underwent uncomplicated phacoemulsification of her left cataract 4 weeks later, with implantation of an Alcon AcrySof IOL in the bag. Postoperative day 1 uncorrected vision was 20/60+2 in the left eye. Eight days later, she complained of irritation in the left eye. Vision had decreased to 20/400 with mild inferior corneal edema. Corticosteroid drops were increased in frequency, and 1 week later, vision was 20/200, pinholing to 20/50. There was some inferior corneal edema with a small nuclear particle visible inferiorly in the angle.
The patient was referred to a retinal specialist for an opinion, and due to the good IOP, mild anterior chamber inflammation and the small nature of the particle despite the inferior corneal edema, observation was recommended. Pachymetry at that time revealed a central thickness of 572 µm in the right eye and 733 µm in the left eye. Due to no improvement of the corneal edema over the next several days, a decision was made to remove the particle surgically. This was done without complications through the original incision using phacoemulsification. On postoperative day 1, vision without correction was 20/150 with a central corneal thickness of 765 µm. Ten days postoperatively, uncorrected vision was 20/60 with a central corneal thickness of 623 µm. Two weeks later, uncorrected vision was 20/40 in the left eye with a clear, compact cornea and quiet anterior chamber. Corneal pachymetry of her left eye was 585 µm.
This case has demonstrated the rapid resolution of corneal edema after removal of a small anterior chamber nuclear particle. Any patient with postoperative progressive corneal edema as measured by pachymetry should be carefully examined for retained nuclear fragments. With appropriate surgical intervention, excellent results can be achieved.
References:
- Doshi RR, Arevalo JF, Flynn HW Jr, Cunningham ET Jr. Evaluating exaggerated, prolonged, or delayed postoperative intraocular inflammation. Am J Ophthalmol. 2010;150(3):295-304.
- Henick AR, Speaker MG, Rosenberg S. Reversible corneal edema after phaco emulsification. Cornea. 1994;13(1):98.
- Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Ophthalmology. 2006;113(11):1949-1953.
- Michael Rosenberg, MD, is the chairman of the Department of Ophthalmology at Hackensack University Medical Center. He can be reached at 30 Prospect Ave., Hackensack, NJ 07601; email: michaelrosenberg@HUMED.com.
- Disclosure: Dr. Rosenberg has no direct financial interest in the products discussed in this article, nor is he a paid consultant for any companies mentioned.
