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Endothelial disease and cataract - preoperative counseling is essential
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A 67-year-old patient with 20/50 best corrected visual acuity, complaints of glare during night driving and difficulty reading was diagnosed with cataract and referred. The exam also showed fairly dense endothelial guttata, which are excrescences on the corneal endothelium most visible with specular reflection.
The patient underwent uncomplicated cataract surgery, and visual acuity recovered initially only to 20/70. Diffuse corneal edema with microcystic corneal epithelial changes were noted. This gradually cleared over 6 weeks, resulting in 20/30 best corrected visual acuity.
This case illustrates some important principles in managing patients with combined cataract and endothelial guttata:
Patients with this combination of diseases need to be prepared for the possibility of a slow visual recovery and the ultimate need for endothelial transplantation with Descemet’s stripping automated endothelial keratoplasty (DSAEK) surgery. I like to give patients numerical odds that a transplant will be necessary. This is based upon my best guess of the capacity of the endothelium.
Preoperative risk factors that suggest severe endothelial compromise and a need for future transplantation include preoperative pachymetry greater than 600 and endothelial cell density less than 1,000 cells/mm2.
Even if corneal edema does not develop after surgery, endothelial guttata themselves can reduce visual acuity because of light scatter. For this reason, all patients with cornea guttata may need counseling about limited vision after surgery.
When recovery of endothelial function is poor after prolonged healing, appropriate consideration should be given to endothelial replacement surgery, such as DSAEK, which generally results in very acceptable vision.
A careful exam of every patient’s endothelium before cataract surgery should confirm the absence of endothelial disease and, when it is present, these principles will help guide the patient toward a happy outcome.