This article is more than 5 years old. Information may no longer be current.
Watch for Fuchs’ in cataract patients and alter technique accordingly, surgeon says
Diagnosing Fuchs’ dystrophy prior to cataract surgery can help the surgeon take steps to reduce the risk of pseudophakic corneal edema.
Click Here to Manage Email Alerts
Identifying Fuchs’ dystrophy is a standard practice all eye care professionals are taught in their various training programs, and it should be part of the preoperative ritual for every cataract patient, said W. Barry Lee, MD. When Fuchs’ is identified preoperatively, the surgeon can alter his or her technique to protect the cornea from damage, he said.
“All eye care professionals know about Fuchs’ dystrophy. But you can get so focused on the cataract during a preoperative evaluation and forget that the presence of corneal guttae could hamper your results postoperatively,” Dr. Lee said. “I think sometimes we’re a little bit forgetful about finding subtle corneal guttae.”
The most common indication for corneal transplantation is pseudophakic corneal edema, Dr. Lee said.
“A large majority of pseudophakic corneal edema cases following cataract surgery occur with patients who have Fuchs’ dystrophy,” he said.
Often, the evaluation for Fuchs’ can slip through the cracks with comanaged care, Dr. Lee said.
| A slit-lamp view using retroillumination through the dilated pupil. The corneal guttae are visible in the posterior cornea against the red reflex in the mildest form of Fuchs’ dystrophy. |
| Diffuse microcystic and stromal edema in a Fuchs’ dystrophy patient with a decompensated cornea after cararact surgery. |
| In the most severe stage of Fuchs’ dystrophy (stage 4), a dense corneal pannus occurs in the area of previous edema. This stage is not seen often because most patients undergo a corneal transplant before the corneal pannus forms. |
| Images: Lee WB |
“In some situations where the preoperative cataract evaluation is done elsewhere, corneal guttae could be missed because you’re focusing more on the cataract rather than looking at the cornea,” he said. “That can easily happen to anyone.”
The first sign of Fuchs’ is corneal guttae, imperfections on the corneal endothelium that have a beaten metal appearance.
“Corneal guttae should be one of the first things you look for in a preoperative evaluation for cataract surgery,” he said. “It certainly can be missed pretty easily because sometimes they are difficult to visualize.”
The guttae can be difficult to find, but high magnification and an appropriate light setting on the slit lamp makes identifying them fairly easy, Dr. Lee said.
“The key is that you should alter your surgical technique if you do see those corneal guttae because there is a significant chance that the cornea may not recover quite as well following cataract surgery,” he said.
Adjusting surgical technique
Dr. Lee said he alters his surgical techniques for cataract patients with Fuchs’ dystrophy to try to avoid corneal endothelial damage.
“If you can alter your surgical technique you can actually get a cataract out quite successfully in somebody with Fuchs’ dystrophy, you just have to use some special techniques that everyone pretty much is familiar with,” he said.
There are four things Dr. Lee changes for all of his Fuchs’ dystrophy patients undergoing cataract surgery: incision site, balanced salt solution, phaco power and viscoelastic.
The first step Dr. Lee takes is to change his surgical incision.
“Most of us now do a clear corneal incision,” he said. “In this case, I do a scleral tunnel incision to completely avoid the cornea altogether.” Dr. Lee said he sometimes uses a limbal incision instead to preserve the corneal endothelial cells.
Next, Dr. Lee uses Alcon’s BSS Plus instead of other irrigating solutions for cataract surgery. One of the components of BSS Plus, glutathione, maintains a barrier between the corneal endothelial cells and acts as a blockade to prevent fluid rushing into the cornea, Dr. Lee said.
“Other irrigating solutions that don’t have glutathione are more prone to developing corneal edema the next day,” Dr. Lee said.
To reduce damage to endothelial cells, Dr. Lee said he also uses a low ultrasound power on his phaco machine.
“The heat energy from the ultrasound can damage the endothelial cells,” he said. “If you use a lower ultrasound power, it is a little more protective for the cells.”
Lastly, Dr. Lee uses a dispersive viscoelastic rather than a cohesive viscoelastic.
“We tend to use cohesives a lot because they provide more form for the anterior chamber during cataract cases,” he said. “But I always use dispersive agents on my Fuchs’ patients for cataract surgery because it coats the endothelium a lot better than the cohesive viscoelastics. It acts like a protective shell.”
“I certainly wouldn’t always do those four things if I was going to do a routine cataract surgery,” Dr. Lee said. “That is the importance of finding guttae on the cornea. If you see that, you know to change the way you’re going to do the procedure.”
| A grass roots patient effort | |
| Signe Maximous, vice president of the Corneal Dystrophy Foundation, was in her 40s when she learned that family genetics would require her to have a corneal transplant. Her father and her aunt both experienced poor vision due to Fuchs’.
She has since had two corneal transplants. Her vision has improved, and her drive to educate Fuchs’ patients and their surgeons is strong. The Corneal Dystrophy Foundation, which sprung out of the online support group, has about 1,300 members internationally. It is designed to educate members as well as urge surgeons to look for the disease. “The disease can strike at any age, and it is hereditary. The appalling thing is this keeps happening over and over again,” Ms. Maximous said. “We want to know how to get through to general ophthalmologists in particular to watch for this disease, and if you see it, either send the patient to a corneal specialist or be really careful when you do [surgery].” For Your Information: |
Increased dystrophy rates
Dr. Lee said published literature estimates 3% to 18% of cataract patients have Fuchs’ dystrophy.
“I think the incidence is higher than what is represented in our literature because it’s becoming very common,” he said. “While we do not completely understand the genetic implications of Fuchs’ dystrophy, we do know that it is autosomal dominant, so it will remain one of the most common corneal dystrophies encountered. Because it’s autosomal dominant, it tends to show up in every generation once it starts in the family.”
For Your Information:
- W. Barry Lee, MD, can be reached at Eye Consultants of Atlanta, 95 Collier Road, Suite 3000, Atlanta, GA 30309; 404-351-2220; fax: 404-351-7070; e-mail: lee0003@aol.com.
- Alcon, maker of BSS Plus, can be reached at 6201 South Freeway, Fort Worth, TX 76134; 817-293-0450; fax: 817-568-6142; Web site: www.alconlabs.com.
- Daniele Cruz is an OSN Staff Writer who covers all aspects of ophthalmology.