NAVIGATING LONGSTANDING CORNEAL EDEMA: DMEK AND CATARACT SURGERY IN COMPLEX CASES

We aim to present a series of excellent postoperative and morphological results in cases of  longstanding corneal edema due to advanced Fuchs endothelial corneal dystrophy, with various degrees of stromal involvement, important stromal haze or fibrosis and in some patients, Bowman layer defects due to recurrent corneal erosions. 

Clinical Emergency Eye Hospital Bucharest

The first case describes a chronic corneal edema in a 74 y.o pseudophakic patient with stage 3 FECD. BCVA was CF. Slit lamp examination highlighted corneal edema, stromal haze, anterior stromal scarring and posterior liniar scarring in the temporal quadrant.  AS-OCT confirmed the clinical findings, with a CCT of 800um with an irregular epithelial layer, focal discontinuities in the Bowman’s layer and posterior stromal fibrosis. Corroborating all the data, surgical management was imposed. Preoperative planning was done and DMEK surgery was performed. At the 3 months follow up examination, BCVA was 0.5, CCT reduced significantly (438um), stromal haze cleared, but a discrete anterior stromal defect persisted. 

The second case comprises longstanding endothelial dysfunction with subsequent corneal edema in a 65 y.o pseudophakic patient. BCVA was CF. Slit lamp examination identified corneal edema, descemetic folds and stromal haze. Furthermore, AS-OCT identified a 800um CCT with stromal hyperreflectivity. Although penetrating keratoplasty would have been the traditional surgical approach in this case, taking in consideration the poor visualization of the anterior segment,  DMEK was proposed. At the 1 month post operative mark, BCVA was 0.6 and CCT normalized.

While both the third and fourth case presented advanced bullous keratopathy, surgical management was adjusted according to the particular characteristics of each one. In both cases BCVA was CF. Cataract surgery in the third case was possible, but difficult, as anterior stromal scarring was present, due to longstanding epithelial dysfunction and recurrent erosions. The approach in this case was sequential because there was a delay in tissue availability. DMEK was performed a week later, with good visual results. The fourth case required a DMEK first, due to the poor visualization of the anterior chamber, secondary to a more pronounced stromal edema compared to the third case. Intraoperative OCT was used to evaluate the orientation of the graft. Postoperatively, in case 3 the BCVA was 0,3 due to stromal irregularities. In case 4, the corneal edema cleared completely, with the BCVA being 0.2 before cataract surgery, which he is scheduled for.

Difficult visualization of the anterior chamber contents used to represent a relative contraindication of DMEK surgery, but now, as a result of good understanding of the graft dynamics, careful preoperative planning and the use of novel technologies, such as intraoperative OCT, we can achieve great visual outcomes for the patients, with the lowest amount of complications, both short and long-term.