14 EyeWorld Asia-Pacific | June 2025 CATARACT Diagnosis Dr. Chan said, anterior segment OCT is particularly useful in diagnosing a Descemet’s membrane detachment or retained lens fragment as the cause for prolonged corneal edema. Dr. Al-Hashimi added that pachymetry can confirm the presence of edema, but emphasized the importance of keeping toxic anterior segment syndrome (TASS) in the differential diagnosis, especially when there is significant corneal edema accompanied by marked anterior chamber inflammation early in the postoperative period. Dr. Goyal explained that corneal edema is readily apparent when Descemet’s folds and stromal clouding are present. However, once these folds resolve, reviewing preoperative data and comparing it to postoperative topography or pachymetry can help determine if persistent edema remains. Treatment Once it’s clear the edema is not resolving, Dr. Al-Hashimi offered a simple but reassuring first step: “Don’t panic.” “Corneal edema often resolves with time. Using a more frequent topical steroid regimen may help speed up recovery. It can take several weeks for complete resolution. Serial pachymetry is helpful in monitoring progress, offering objective reassurance to patients—even when their vision seems unchanged initially,” he said. “If no improvement is seen after 4 weeks,there is a high probability the patient will ultimately need an endothelial keratoplasty. Sodium chloride ophthalmic solution drops or ointment may help, but this typically is only useful when there is epithelial edema.” Dr. Chan said treatment of the edema depends on its etiology and whether there was any pre-existing endothelial compromise or disease present. “If a retained nuclear cataract piece is removed within a week to a month, the cornea, if otherwise healthy, can typically clear up in 1–4 weeks,” she said. “If a Descemet’s membrane detachment is rebubbled within 1 to 3 weeks, corneal clarity can usually be restored. However, beyond 1 month, the membrane may fibrose and lose the ability to conform to the stroma, necessitating DMEK. A history of HSV endothelial disease and/or iritis may also cause the endothelial cells to be dysfunctional or deficient, leading to a greater risk of prolonged corneal edema after cataract surgery, especially if other intraoperative risk factors are not mitigated.” Dr. Goyal said intervention becomes necessary when edema persists beyond 1 month. She starts treatment with sodium chloride drops or ointment. If this does not help, she would consider a rho-kinase (ROCK) inhibitor, which she said “can help our endothelial cells function at their best and are low risk.” If a ROCK inhibitor is going to help, it would improve within a few days to weeks. If improvement does not occur within a few days to weeks, she then considers endothelial keratoplasty (DMEK), though she hopes future options will include endothelial cell therapy. Dr. Al-Hashimi warned that long-standing edema, especially with bullae and microcystic changes, can result in subepithelial scarring that limits vision—even after a successful endothelial keratoplasty. “It is best to address unresolved edema surgically within a few months to prevent permanent scarring,” he said. Dr. Chan added that patients may experience significant discomfort from ruptured bullae or a persistent foreign body sensation due to microcystic edema. She emphasized the importance of a thorough postoperative evaluation for corneal edema following cataract surgery. “Always assess for Descemet’s membrane detachment or retained nucleus piece as well because managing these problems as soon as possible can successfully reverse postoperative corneal edema.” About the Physicians Saba Al-Hashimi, MD | Associate Professor of Ophthalmology, University of California, Los Angeles, Los Angeles, California | alhashimi@jsei.ucla.edu Clara Chan, MD | Associate Professor of Ophthalmology, University of Toronto, Toronto, Canada | clarachanmd@gmail.com Himani Goyal, MD | Clinical Associate Professor, NYU Langone Health New York, New York | himani.goyal.md@gmail.com Relevant Disclosures Al-Hashimi: None Chan: Théa Goyal: Alcon This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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