43 EyeWorld Asia-Pacific | December 2024 When evaluating corneal edema after cataract surgery, Dr. Syed measures central corneal thickness with a pachymeter at the first postoperative visit to record a baseline against which to compare follow-up evaluations. “While specular microscopy may be helpful in confirming endothelial cell loss, I do not always find it helpful in the setting of significant corneal edema because the measurements are often unreliable,” she said. “Another test I may use is anterior segment optical coherence tomography (AS-OCT), especially in cases where the edema may be focal. I have evaluated cases of persistent postoperative corneal edema that were actually Descemet’s membrane detachments that we identified on AS-OCT, and these cleared up with placement of an air bubble in the anterior chamber and face-up positioning by the patient. Identification of this diagnosis may prevent the patient from undergoing an unnecessary corneal transplant.” When managing postoperative corneal edema, Dr. Syed keeps two goals in mind. The first is to eliminate aggravators of endothelial compromise, and the second is to treat corneal edema itself. In cases of immediate postoperative corneal edema, Dr. Syed said inflammation from surgical trauma often contributes to endothelial dysfunction. Topical steroids reduce inflammation as well as corneal edema in these situations. In the presence of a quiet eye, a steroid does not usually provide any direct benefit, instead causing side effects such as increased intraocular pressure. Another approach to medical management includes hypertonic saline, which accelerates corneal deturgescence. “This treatment does not directly promote endothelial viability,” she said, “but rather provides symptomatic relief. Hypertonic saline works well in mild edema but not as well in advanced cases. Patients should be counseled on the likelihood of long-term hypertonic saline therapy if the goal is to avoid endothelial keratoplasty.” Dr. Syed noted that rho kinase (ROCK) inhibitors are an alternative approach to manage postoperative corneal edema. The ROCK pathway plays a role in regulating endothelial cell migration, proliferation, and adhesion, and ROCK inhibitors support endothelial wound healing and accelerate corneal deturgescence after surgery.6 Options for ROCK inhibition include netarsudil 0.02% and ripasudil 0.4%. Both formulations may improve endothelial cell viability after surgical trauma. “I typically use the ROCK inhibitor 4 times daily for 4–6 weeks postoperatively or until corneal deturgescence is noted, although I will titrate based on tolerability,” she said. If edema persists a couple of months out, Dr. Price said there’s a good chance it’s not going to clear and to consider an endothelial keratoplasty. For a non-Fuchs patient, he’ll do cataract surgery alone when there’s a low cell count because if you use a good technique, the patient can maintain a low cell count for years with or without a previous graft. “Fuchs is a different story. The guttae affect vision,” he said. “I operate on people with no apparent edema but who have guttae causing glare and haze, and we see improvements for those patients.” If they have guttae and a cataract, Dr. Price recommends treating both at the same time. Patients can have some improvement from just treating the cataract, but often, that may lead to corneal decompensation. CORNEA
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