Five pearls for protecting the endothelium during cataract surgery

 

Take-Home Message: Five pearls should be considered to protect the endothelium after cataract surgery. These involve consideration of the phacoemulsification techniques and technology, use of viscoelastics, irrigation and aspiration techniques, intracameral medications, and postoperative medications.

 

By Lynda Charters; Reviewed by Terry Kim, MD

Durham, NC-Protecting the endothelium during cataract surgery can be a challenge for seasoned or novice surgeons alike depending on the status of patients, according to Terry Kim, MD.

Factors are as varied as the patients’ cases, said Dr. Kim, professor of ophthalmology, Duke University School of Medicine, and director of fellowship programs, Cornea and Refractive Surgery Services, Duke University Eye Center, Durham, NC.

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Long-recognized non-corneal risk factors to watch out for to prevent injury to the corneal endothelial cells are a shallow or crowded anterior chamber, the density of the nucleus, small pupils, the volume of the infusion, the amount of ultrasound energy used, and the type of IOL to be implanted, he said.

Even more important are the following corneal characteristics that may be predictive of problems-i.e., older patient age characterized by a lower endothelial cell density and the presence of Fuchs’ dystrophy and diabetes mellitus, he noted.

Surgeons have a number of factors to consider in their decision making during the preoperative testing. Specifically, in high-risk patients, they must decide whether to perform a cataract extraction or a Descemet’s stripping endothelial keratoplasty (DSEK) triple procedure that includes corneal transplant, cataract removal, and IOL insertion.

During preoperative testing, surgeons should be aware of any symptoms the patient may have-the severity of guttae (specular reflection), stromal edema, lens density, and the anterior chamber depth observed during the slit lamp examination, and any other comorbidities. The examination also includes pachymetry and specular microscopy.

Dr. Kim offered five pearls for protecting the endothelium that include consideration of the:

• Phacoemulsification techniques and technology.

• Use of viscoelastics.

• Irrigation and aspiration (I&A) techniques.

• Intracameral medications.

• Postoperative medications.

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