Protecting the corneal endothelial cells during cataract surgery

ByUday Devgan, MD

Patients who have both Fuchs' endothelial dystrophy and cataracts pose a challenging situation. The cornea continues to decompensate with time, but this can be hastened by the side effects of cataract surgery. The ultrasonic energy from phacoemulsification as well as the fluid flow through the eye can cause further damage to the corneal endothelial cells.

Slit lamp appearance of Fuchs’ endothelial dystrophy.

In evaluating these patients, the cornea should be carefully examined with particular regard to the corneal endothelium. If there is mild stromal edema, this can be noted at the slit lamp as well as by increased thickness on pachymetry. A specular or confocal microscope allows for direct visualization of the endothelial cells to examine cell density and morphology.

Intraoperatively, the flow rate should be decreased to minimize the amount of balanced saline solution that is put through the eye. Phaco power modulations can be used to help limit the amount of ultrasound energy placed into the eye. A mechanical method of nucleus disassembly such as chopping can further decrease the required ultrasound energy. And most importantly, a dispersive viscoelastic should be used to provide protection of the endothelial cells during surgery. And periodically, during the surgery, more dispersive viscoelastic can be applied for continued protection.

Postoperatively, these patients can do very well; however, they may have a prolonged course of healing. I tell patients to remember that Fuchs' is a progressive condition and that they may decompensate years after the cataract surgery. Fortunately, new endothelial transplantation techniques provide a remedy for this situation as well.