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POST-OPERATIVE-CORNEAL
EDEMA
a complication of cataract surgery
PRECEPTOR: Dr (MRS) UZZI I.A OKHUOSAMI F.S Pharm.D
OUTLINE
 Cataract (Pathophysiology, surgery, complications of surgery)
 Corneal edema
 Corneal edema as a complication of cataract surgery
(pathophysiology, epidemiology)
 Management of post-operative corneal edema
 Conclusion
 References
2
PHYSIO-ANATOMY OF THE
HUMAN EYE
3
WHAT IS CATARACT???
 A cataract is a clouding of the natural intraocular crystalline
lens that focuses the light entering the eye onto the retina.
This cloudiness can cause a decrease in vision and may lead
to eventual blindness if left untreated.
 Cataract can also be defined as complete or partial opacity of
the ocular lens.
4
PATHOPHYSIOLOGY OF CATARACT
The clear lens of the
eye transmits light rays
entering the eye and
focuses them on the
retina
With aging, lens proteins
progressively denature
causing increase in
density and yellowish-
brown coloration of the
lens
The resultant cloudy lens
lacks the ability to transmit
and focus light rays on the
retina
This manifests as blurry
vision or loss of vision in
advanced cases
5
FIG 1.1
A healthy human eye
Jagat. R(2012) MEAJO. Pediatric Cataract
surgery. Vol. 19:1
FIG 1.2
Unilateral cataract in the right eye
6
CATARACT SURGERY
Eye
drops(containing an
anesthetic) that
dilate the pupils will
be administered
A tiny cut is made
in the cornea
through which a
probe is inserted
Probe breaks up
cloudy lens into
small pieces which
are sucked out
The artificial lens is
inserted through the
cut and sits in the
lens capsule. It
unfolds when in
position.
7
FIG 1.3
Removal and replacement of an infected lens with an artificial lens during cataract surgery
COMPLICATIONS OF CATARACT
SURGERY
 Modern cataract surgery is safe in more than 95% of patients.
In a small number of cases, an intra-operative posterior
capsular rupture can lead to vitreous loss or a dropped
nucleus and can increase the risk of post-operative
complications.
 CORNEAL EDEMA and CYSTOID MACULAR EDEMA are
common post-surgical complications that occur due to
persistent swelling in the cornea as seen in corneal edema or
in the retina as in cystoid macular edema. In both cases,
patients may notice blurred, foggy vision. The risk of either
occurring is around 1 in 100.
9
POST-SURGICAL-
CORNEAL-EDEMA
10
FIG 1.4
Anatomy of the cornea showing it’s five membranes
11
CORNEAL EDEMA
 The endothelium continuously pumps fluid from the cornea
keeping it dry and clear as corneal clarity is essential for clear
vision.
 Corneal edema is the hydration(swelling) of the corneal
stroma due to corneal endothelial injury/damage causing
decreased visual acuity.
 It may occur naturally as in the genetic condition; Fuch’s
dystrophy or as a complication of cataract surgery.
12
CORNEAL EDEMA AS A
COMPLICATION OF CATARACT
SURGERY
 Corneal edema often resolves within a few days or weeks post-
surgery.
 If the cornea was not healthy prior to surgery, high intraocular
pressure(IOP) can cause the cornea to fail, and severe edema
can result.
 Edema may persist for months after surgery. This may be the
case in Fuch’s dystrophy or extremely dense/difficult to remove
cataracts.
 Some early designs of lenses implanted during surgery caused
injury to the endothelium. However, these implant designs are no
longer manufactured.
13
PATHOPHYSIOLOGY OF POST-
OPERATIVE CORNEAL EDEMA
Corneal tissue
must remain thin
and transparent for
clear vision
The corneal
endothelium
pumps fluid out of
the cornea keeping
it dry and clear
Cataract surgery with
or without pre-
existing Fuch’s
dystrophy can injure
the corneal
endothelium
Upon injury,
surviving cells
change shape and
grow larger to fill the
spaces left by the
destroyed cells
When a lot of cells
are damaged, the
cornea stroma will
be flooded by fluids
causing the
swelling (edema)
14
FIG 1.5
The hydrated corneal stroma causes reduced
visual performance and blurred vision as seen in
the image above
FIG1.6
Pseudophakic bullous keratopathy (PBK). Large multiple
bullae, such as depicted here, are associated with
moderate to severe pain and discomfort.
15
EPIDEMIOLOGY
 The exact incidence rate for corneal edema is unknown. It is
however, estimated that 1% of patients undergoing cataract
surgery will develop this problem.
CORNEAL OEDEMA
AGE SEX RACE
Older
patients(
>50year
s) are
more
prone
No
known
associ
ation
No
known
associ
ation
16
EPIDEMIOLOGY cont’d
 Despite an increase in the overall number of cataract
surgeries performed, cases of ABK and PBK have decreased.
 The overall drop in the incidence of post-operative corneal
edema reflects the rapid development and improvement of
both intraocular lens design and cataract surgical technique.
17
TREATMENT/MANAGEMENT
 Treatment of corneal edema is based on the exact cause.
There is no treatment to promote the healing of the destroyed
endothelial cells, though the extent of the edema can be
controlled.
A. HYPERTONIC DROPS AND OINTMENTS: Patients with
early/mild corneal edema may benefit from the use of
hypertonic/concentrated saline agents to reduce corneal
thickness.
 Examples: 2% and 5% Hypertonic saline solution and
ointment.
 Mode of action: These agents work by creating an osmotic
gradient via a tear film outside the cornea that pulls fluid from
the cornea.
18
TREATMENT cont’d
As evaporation from the tear film is minimal at night with the
eyes closed (therefore, the tears are less hypertonic), corneal
edema tends to be worse in the morning.
Use of hypertonic Nacl 5% ointment at night and/or a
hypertonic solution early in the morning limits this build-up of
edema.
A typical regimen is Hypertonic Nacl (Muro128®) 2% drops
used hourly in the affected eye until noon (4-5 times).
As the day progresses, evaporation from the tear film begins
to create relative hyper-tonicity of the tears, drawing fluid from
the cornea.
19
TREATMENT cont’d
 Side effects: Nil or minor (e.g mild burning or irritation).
Rare severe side effects include; severe allergic reactions,
eye pain and changes in vision.
B. ANTI-INFLAMMATORY AND INTRA-OCULAR
PRESSURE(IOP)-LOWERING AGENTS: Treatment of
edema in eyes with borderline endothelial function should
be focused on ocular inflammation and elevated
intraocular pressure if present.
The IOP inside the eye may become elevated due to
inflammation in the eye following surgery causing the
drainage angle inside the eye to be blocked.
If the pressure is 25mmHg - 35mmHg, the patient should
begin IOP-lowering drops.
20
TREATMENT cont’d
 Examples of anti-inflammatory agents: Ketorolac 0.4% qid,
Diclofenac 0.1% (Voltaren®) t.i.d and Corticosteroids such as
Prednisolone acetate 1% solution 2-4 times daily used for not
more than 10 days.
 Mode of action: NSAIDs act by blocking the cyclo-oxygenase
enzymes, COX-1 and COX-2(mediates production of
prostaglandins that contribute to the inflammatory response and
ocular disease). Inhibition of COX-2 determines the clinical
efficacy of an ophthalmic NSAID.
 Side effects: Mild effects include; Burning and stinging, itchy
eyes, dizziness, headache. Serious effects include; Eye pain,
eye discharge and blurred vision.
21
TREATMENT cont’d
 Examples of IOP-lowering drugs: Selective alpha 2-adrenergic
agonists such as Brimonidine 0.2% (Alphagan®) t.d.s or beta-
adrenergic blockers such as Timolol 0.25% and 0.5% b.d
ophthalmic preparations.
 Mode of action: These drugs lower IOP by reducing the
production of aqueous humor and facilitating it’s outflow.
 Side effects: Timolol may cause eye irritation, double vision,
drowsiness and in severe cases, fainting, breathing difficulties
and sudden weight gain.
Brimonidine may cause blurred vision, red/swollen eyelids,
sore throat and in sever cases, blind spots, dizziness and
rash.
22
TREATMENT cont’d
C. SURGICAL PROCEDURES: These include; Anterior
Stromal Puncture, Bandage contact lenses and Corneal
Transplant.
1) Anterior Stromal Puncture: Patients who have poor visual
potential and severe pain can benefit from this safe, simple
cost-effective procedure.
 Small superficial punctures are placed in the affected area
of the cornea with depths just at the Bowman’s layer.
 A bandage contact lens is the applied as an adjunct and left
for 7-14 days to hold the healing epithelium in place as it
grows back over the cornea.
23
TREATMENT cont’d
2) Bandage contact lenses: These are soft lenses useful for the
temporary relief of pain and discomfort due to bullous
keratopathy.
 They must not be too tight as this may worsen the edema
especially when used at night.
 They can increase the risk of infections. Therefore, antibiotics
are prescribed for corneal edema patients using Bandage
lenses.
 A broad-spectrum antibiotic such as Polymyxin-B ophthalmic
drop/ointment used 2-4 times a day for 7-10 days is
recommended.
Bandage contact lens
24
TREATMENT cont’d
3) Corneal Transplant: Ultimately, if vision is substantially impaired,
the surgeon can transplant the entire cornea.
 Corneal transplant, when paired with glasses or contact lenses,
often restores vision to a significant degree.
 Only the endothelial layer of cells may be replaced in cases of
advanced edema resulting in fewer side effects than a full
transplant.
 The procedures used are called Deep Lamellar Endothelial
Keratoplasty or Descemet’s Stripping Endothelial Keratoplasty.
25
CONCLUSION
 Surgical removal of cataract is a routine and safe procedure.
Patients are advised to report any complications occurring
post-surgery to their physician(s). Corneal edema can be
effectively resolved with the restoration of vision to a
significant degree.
26
REFERENCES
 Alpa S. Patel MD(2014). Cataract. American Academy Of Ophthalmology.
Available from eyewiki.aao.org/Cataract
 Ocampo J, etal(2014). Senile Cataract. eMedicine [MedScape]. Available from
emedicine.medscape.com/article/1210914-overview
 Christian Nordqvist(2014). What are Cataracts? What causes Cataracts?
Medical News Today. Available from
medicalnewstoday.com/articles/157510.php
 Elsie C, Omar A(2010). Complications of Cataract Surgery. Clinical and
Experimental Optometry. DOI: 10.1111/j.1444-0938.2010.00516.x
 University of Washington Medical Center(2015). Corneal Edema. Available from
uwmedicine.org/health-library/Pages/corneal-edema.aspx
 Brunton L, Chabner B, Knollman B(2010). Corneal endothelium. Goodman &
Gilman’s The Pharmacological Basis of THERAPEUTICS (12th ed). Mc Graw Hill
Medical, California: pp1774-1775
 Taravella M, etal(2014). Post-Operative-Corneal-Edema. eMedicine
[Medscape]. Available from emedicine.medscape.com/article/1193218-overview
27
 Drugs.com [ Micromedex® , Cerner Multum™ , etal(2015) ]. Sodium chloride
drops: Indications, Side Effects, Warnings. Available from drugs.com/cdi/sodium-
chloride-drops.html
 The American Society of Health-System Pharmacists(2011). Diclofenac
Ophthalmic. US. National Library of Medicine[MedlinePlus]. Available from
nlm.nih.gov/medlineplus/druginfo/meds/a606003.html
 The American Society of Health-System Pharmacists(2010). Timolol Ophthalmic.
US. National Library of Medicine[MedlinePlus]. Available from
nlm.nih.gov/medlineplus/druginfo/meds/a682043.html
 The American Society of Health-System Pharmacists(2011). Brimonidine
Ophthalmic. US. National Library of Medicine[MedlinePlus]. Available from
nlm.nih.gov/medlineplus/druginfo/meds/a601232.html
 Zauberman N, etal(2014). Anterior Stromal Puncture for the Treatment of
Recurrent Corneal Erosion Syndrome: Patient Clinical Features and Outcomes.
American Journal of Ophthalmology Vol. 157, Issue 2: pp273-279
 Fan M, etal(2014). Anterior Stromal Puncture. American Academy of
Ophthalmologists. Available from eyewiki.aao.org/Anterior_Stromal_Puncture
 Taravella M, etal(2014). Post-Operative-Corneal-Edema. eMedicine [Medscape].
Available from emedicine.medscape.com/article/1193218-treatment
28
THANK YOU
FOR
LISTENING!!
29

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POST-OPERATIVE-CORNEAL-EDEMA

  • 1. POST-OPERATIVE-CORNEAL EDEMA a complication of cataract surgery PRECEPTOR: Dr (MRS) UZZI I.A OKHUOSAMI F.S Pharm.D
  • 2. OUTLINE  Cataract (Pathophysiology, surgery, complications of surgery)  Corneal edema  Corneal edema as a complication of cataract surgery (pathophysiology, epidemiology)  Management of post-operative corneal edema  Conclusion  References 2
  • 4. WHAT IS CATARACT???  A cataract is a clouding of the natural intraocular crystalline lens that focuses the light entering the eye onto the retina. This cloudiness can cause a decrease in vision and may lead to eventual blindness if left untreated.  Cataract can also be defined as complete or partial opacity of the ocular lens. 4
  • 5. PATHOPHYSIOLOGY OF CATARACT The clear lens of the eye transmits light rays entering the eye and focuses them on the retina With aging, lens proteins progressively denature causing increase in density and yellowish- brown coloration of the lens The resultant cloudy lens lacks the ability to transmit and focus light rays on the retina This manifests as blurry vision or loss of vision in advanced cases 5
  • 6. FIG 1.1 A healthy human eye Jagat. R(2012) MEAJO. Pediatric Cataract surgery. Vol. 19:1 FIG 1.2 Unilateral cataract in the right eye 6
  • 7. CATARACT SURGERY Eye drops(containing an anesthetic) that dilate the pupils will be administered A tiny cut is made in the cornea through which a probe is inserted Probe breaks up cloudy lens into small pieces which are sucked out The artificial lens is inserted through the cut and sits in the lens capsule. It unfolds when in position. 7
  • 8. FIG 1.3 Removal and replacement of an infected lens with an artificial lens during cataract surgery
  • 9. COMPLICATIONS OF CATARACT SURGERY  Modern cataract surgery is safe in more than 95% of patients. In a small number of cases, an intra-operative posterior capsular rupture can lead to vitreous loss or a dropped nucleus and can increase the risk of post-operative complications.  CORNEAL EDEMA and CYSTOID MACULAR EDEMA are common post-surgical complications that occur due to persistent swelling in the cornea as seen in corneal edema or in the retina as in cystoid macular edema. In both cases, patients may notice blurred, foggy vision. The risk of either occurring is around 1 in 100. 9
  • 11. FIG 1.4 Anatomy of the cornea showing it’s five membranes 11
  • 12. CORNEAL EDEMA  The endothelium continuously pumps fluid from the cornea keeping it dry and clear as corneal clarity is essential for clear vision.  Corneal edema is the hydration(swelling) of the corneal stroma due to corneal endothelial injury/damage causing decreased visual acuity.  It may occur naturally as in the genetic condition; Fuch’s dystrophy or as a complication of cataract surgery. 12
  • 13. CORNEAL EDEMA AS A COMPLICATION OF CATARACT SURGERY  Corneal edema often resolves within a few days or weeks post- surgery.  If the cornea was not healthy prior to surgery, high intraocular pressure(IOP) can cause the cornea to fail, and severe edema can result.  Edema may persist for months after surgery. This may be the case in Fuch’s dystrophy or extremely dense/difficult to remove cataracts.  Some early designs of lenses implanted during surgery caused injury to the endothelium. However, these implant designs are no longer manufactured. 13
  • 14. PATHOPHYSIOLOGY OF POST- OPERATIVE CORNEAL EDEMA Corneal tissue must remain thin and transparent for clear vision The corneal endothelium pumps fluid out of the cornea keeping it dry and clear Cataract surgery with or without pre- existing Fuch’s dystrophy can injure the corneal endothelium Upon injury, surviving cells change shape and grow larger to fill the spaces left by the destroyed cells When a lot of cells are damaged, the cornea stroma will be flooded by fluids causing the swelling (edema) 14
  • 15. FIG 1.5 The hydrated corneal stroma causes reduced visual performance and blurred vision as seen in the image above FIG1.6 Pseudophakic bullous keratopathy (PBK). Large multiple bullae, such as depicted here, are associated with moderate to severe pain and discomfort. 15
  • 16. EPIDEMIOLOGY  The exact incidence rate for corneal edema is unknown. It is however, estimated that 1% of patients undergoing cataract surgery will develop this problem. CORNEAL OEDEMA AGE SEX RACE Older patients( >50year s) are more prone No known associ ation No known associ ation 16
  • 17. EPIDEMIOLOGY cont’d  Despite an increase in the overall number of cataract surgeries performed, cases of ABK and PBK have decreased.  The overall drop in the incidence of post-operative corneal edema reflects the rapid development and improvement of both intraocular lens design and cataract surgical technique. 17
  • 18. TREATMENT/MANAGEMENT  Treatment of corneal edema is based on the exact cause. There is no treatment to promote the healing of the destroyed endothelial cells, though the extent of the edema can be controlled. A. HYPERTONIC DROPS AND OINTMENTS: Patients with early/mild corneal edema may benefit from the use of hypertonic/concentrated saline agents to reduce corneal thickness.  Examples: 2% and 5% Hypertonic saline solution and ointment.  Mode of action: These agents work by creating an osmotic gradient via a tear film outside the cornea that pulls fluid from the cornea. 18
  • 19. TREATMENT cont’d As evaporation from the tear film is minimal at night with the eyes closed (therefore, the tears are less hypertonic), corneal edema tends to be worse in the morning. Use of hypertonic Nacl 5% ointment at night and/or a hypertonic solution early in the morning limits this build-up of edema. A typical regimen is Hypertonic Nacl (Muro128®) 2% drops used hourly in the affected eye until noon (4-5 times). As the day progresses, evaporation from the tear film begins to create relative hyper-tonicity of the tears, drawing fluid from the cornea. 19
  • 20. TREATMENT cont’d  Side effects: Nil or minor (e.g mild burning or irritation). Rare severe side effects include; severe allergic reactions, eye pain and changes in vision. B. ANTI-INFLAMMATORY AND INTRA-OCULAR PRESSURE(IOP)-LOWERING AGENTS: Treatment of edema in eyes with borderline endothelial function should be focused on ocular inflammation and elevated intraocular pressure if present. The IOP inside the eye may become elevated due to inflammation in the eye following surgery causing the drainage angle inside the eye to be blocked. If the pressure is 25mmHg - 35mmHg, the patient should begin IOP-lowering drops. 20
  • 21. TREATMENT cont’d  Examples of anti-inflammatory agents: Ketorolac 0.4% qid, Diclofenac 0.1% (Voltaren®) t.i.d and Corticosteroids such as Prednisolone acetate 1% solution 2-4 times daily used for not more than 10 days.  Mode of action: NSAIDs act by blocking the cyclo-oxygenase enzymes, COX-1 and COX-2(mediates production of prostaglandins that contribute to the inflammatory response and ocular disease). Inhibition of COX-2 determines the clinical efficacy of an ophthalmic NSAID.  Side effects: Mild effects include; Burning and stinging, itchy eyes, dizziness, headache. Serious effects include; Eye pain, eye discharge and blurred vision. 21
  • 22. TREATMENT cont’d  Examples of IOP-lowering drugs: Selective alpha 2-adrenergic agonists such as Brimonidine 0.2% (Alphagan®) t.d.s or beta- adrenergic blockers such as Timolol 0.25% and 0.5% b.d ophthalmic preparations.  Mode of action: These drugs lower IOP by reducing the production of aqueous humor and facilitating it’s outflow.  Side effects: Timolol may cause eye irritation, double vision, drowsiness and in severe cases, fainting, breathing difficulties and sudden weight gain. Brimonidine may cause blurred vision, red/swollen eyelids, sore throat and in sever cases, blind spots, dizziness and rash. 22
  • 23. TREATMENT cont’d C. SURGICAL PROCEDURES: These include; Anterior Stromal Puncture, Bandage contact lenses and Corneal Transplant. 1) Anterior Stromal Puncture: Patients who have poor visual potential and severe pain can benefit from this safe, simple cost-effective procedure.  Small superficial punctures are placed in the affected area of the cornea with depths just at the Bowman’s layer.  A bandage contact lens is the applied as an adjunct and left for 7-14 days to hold the healing epithelium in place as it grows back over the cornea. 23
  • 24. TREATMENT cont’d 2) Bandage contact lenses: These are soft lenses useful for the temporary relief of pain and discomfort due to bullous keratopathy.  They must not be too tight as this may worsen the edema especially when used at night.  They can increase the risk of infections. Therefore, antibiotics are prescribed for corneal edema patients using Bandage lenses.  A broad-spectrum antibiotic such as Polymyxin-B ophthalmic drop/ointment used 2-4 times a day for 7-10 days is recommended. Bandage contact lens 24
  • 25. TREATMENT cont’d 3) Corneal Transplant: Ultimately, if vision is substantially impaired, the surgeon can transplant the entire cornea.  Corneal transplant, when paired with glasses or contact lenses, often restores vision to a significant degree.  Only the endothelial layer of cells may be replaced in cases of advanced edema resulting in fewer side effects than a full transplant.  The procedures used are called Deep Lamellar Endothelial Keratoplasty or Descemet’s Stripping Endothelial Keratoplasty. 25
  • 26. CONCLUSION  Surgical removal of cataract is a routine and safe procedure. Patients are advised to report any complications occurring post-surgery to their physician(s). Corneal edema can be effectively resolved with the restoration of vision to a significant degree. 26
  • 27. REFERENCES  Alpa S. Patel MD(2014). Cataract. American Academy Of Ophthalmology. Available from eyewiki.aao.org/Cataract  Ocampo J, etal(2014). Senile Cataract. eMedicine [MedScape]. Available from emedicine.medscape.com/article/1210914-overview  Christian Nordqvist(2014). What are Cataracts? What causes Cataracts? Medical News Today. Available from medicalnewstoday.com/articles/157510.php  Elsie C, Omar A(2010). Complications of Cataract Surgery. Clinical and Experimental Optometry. DOI: 10.1111/j.1444-0938.2010.00516.x  University of Washington Medical Center(2015). Corneal Edema. Available from uwmedicine.org/health-library/Pages/corneal-edema.aspx  Brunton L, Chabner B, Knollman B(2010). Corneal endothelium. Goodman & Gilman’s The Pharmacological Basis of THERAPEUTICS (12th ed). Mc Graw Hill Medical, California: pp1774-1775  Taravella M, etal(2014). Post-Operative-Corneal-Edema. eMedicine [Medscape]. Available from emedicine.medscape.com/article/1193218-overview 27
  • 28.  Drugs.com [ Micromedex® , Cerner Multum™ , etal(2015) ]. Sodium chloride drops: Indications, Side Effects, Warnings. Available from drugs.com/cdi/sodium- chloride-drops.html  The American Society of Health-System Pharmacists(2011). Diclofenac Ophthalmic. US. National Library of Medicine[MedlinePlus]. Available from nlm.nih.gov/medlineplus/druginfo/meds/a606003.html  The American Society of Health-System Pharmacists(2010). Timolol Ophthalmic. US. National Library of Medicine[MedlinePlus]. Available from nlm.nih.gov/medlineplus/druginfo/meds/a682043.html  The American Society of Health-System Pharmacists(2011). Brimonidine Ophthalmic. US. National Library of Medicine[MedlinePlus]. Available from nlm.nih.gov/medlineplus/druginfo/meds/a601232.html  Zauberman N, etal(2014). Anterior Stromal Puncture for the Treatment of Recurrent Corneal Erosion Syndrome: Patient Clinical Features and Outcomes. American Journal of Ophthalmology Vol. 157, Issue 2: pp273-279  Fan M, etal(2014). Anterior Stromal Puncture. American Academy of Ophthalmologists. Available from eyewiki.aao.org/Anterior_Stromal_Puncture  Taravella M, etal(2014). Post-Operative-Corneal-Edema. eMedicine [Medscape]. Available from emedicine.medscape.com/article/1193218-treatment 28