Fuchs’ dystrophy can be managed in patients with cataract

Fuchs’ dystrophy with cataract can be treated surgically in a number of ways. Descemet’s stripping endothelial keratoplasty (DSEK) offers a tremendous advance in the treatment, said Jonathan Rubenstein, MD, professor of ophthalmology, Rush University Medical Center, Chicago.

Fuchs’ dystrophy is a bilateral, non-inflammatory, progressive loss of endothelium that results in reduced vision and is a leading cause of endothelial dysfunction. One important sign of Fuchs’ dystrophy is guttata that first appears centrally and eventually has a beaten metal appearance. Decreased endothelial cell count, corneal edema, Descemet’s folds, cataract, and glaucoma are other signs. Patients present with early morning blurring of visual acuity from corneal edema, disrupted quality of vision secondary to guttata and, eventually, continuous blurred vision, glare, and halos. Pain and foreign body sensation and worse visual acuity from epithelial edema are seen later. Visual acuity also can decrease from concomitant cataract and glaucoma.

Treatment is needed when there is loss of visual acuity or corneal pain. Type of treatment depends on the degree of endothelial dysfunction. Type of surgery depends on the assessment of visual impairment from the cornea versus cataract. Surgeons must decide between performing cataract surgery only, corneal surgery (penetrating keratoplasty [PK] or DSEK) only, combined PK/phaco/posterior chamber lens, or combined DSEK/phaco/posterior chamber lens.

DSEK involves lamellar transplantation of a thin piece of posterior corneal stroma with Descemet’s membrane and healthy endothelium. Advantages are that DSEK is performed through a small incision and the procedure preserves the ocular surface and minimizes stress to the corneal stem cells. Also, there is minimal induced astigmatism and no prolonged period of suture removal or corneal suture-related complications, he said.

In addition, there is no significant change in spherical equivalent power of the cornea. Finally, DSEK facilitates quicker recovery of the visual acuity; 20/40 visual acuity is possible by 1 week after surgery, Dr. Rubenstein said.

DSEK is associated with a steep learning curve, the potential for more endothelial cell loss, increased primary graft failure, and dislocation of the posterior lamellar graft in 5% to 40% of cases during the first postoperative week. DSEK may require a second procedure that involves rebubbling of the graft and replacement of the posterior lenticule. Best-corrected visual acuity is limited by the lamellar interface, with most cases reaching 20/25 to 20/30.