Pravin K Vaddavalli – [email protected] Rudy Nuijts – [email protected] Muriel Doors – [email protected] Update 21

contacts

FUCHS’ DYSTROPHY Debate explores optimal approach for treating in patients with Fuchs’ dystrophy by Dermot McGrath in Abu Dhabi

s it better to perform a combined visual function in patients with Fuchs’ cataract and Descemet’s stripping dystrophy,” he said. endothelial keratoplasty (DSEK) in patients with Fuchs’ dystrophy or Appropriate selection Presenting Ishould surgeons opt instead for a staged the case for a staged procedure, Dr Nuijts approach of two separate procedures? said that it is first of all important to establish At a special debate session held during the whether the primary cause of vision loss is World Congress, Pravin K cataract or Fuchs’ endothelial dystrophy. Vaddavalli MD argued the case for the former “The criteria for the selection can be based Rudy Nuijts MD, PhD approach while Rudy Nuijts MD, PhD, on corneal thickness, but also signs such as outlined the benefits of a staged approach. early morning decompensation, endothelial Dr Vaddavalli, associate ophthalmologist Courtesy of cell density, firmness of the cataract and Ultrasound time (left) and Cumulative Dissipated Energy (CDE) (right) for each nucleus density grade, with longitudinal at the LV Prasad Eye Institute, Hyderabad, quality of vision,” he said. phacoemulsification in red and torsional phacoemulsification in blue bars. P-values: independent sample t-test between the two groups India, said that while specific cases may Once the patient has been identified warrant a staged procedure depending on as being a good candidate for a staged “As well as the intraoperative disadvantages corneal graft rejection of up to 9 per cent and the severity of the cataract and progression procedure, the main preoccupation of of a smaller capsulorhexis, and issues with we also have IOP pressure spikes that may be of the dystrophy, there were valid arguments the surgeon is to prevent postoperative diaphragm visibility and mobility, caused by the use of corticosteroids in up to in favour of combining the procedures for corneal decompensation from the cataract there are also the postoperative problems of 30 per cent of cases,” he said. many patients. “The main reason why I think procedure, said Dr Nuijts. “The risk the unpredictability of the refractive effect, Dr Nuijts said that phacoemulsification we should do it together is because it is one factors for endothelial cell loss are the since not all eyes with DSEK improve and might be considered as the preferred option surgery, and the results of combined DSEK firmness of the nucleus, shorter eyes, longer there is a continuing loss of endothelial cells for a standalone procedure if the corneal with cataract surgery have excellent visual phacoemulsification time and complications. after keratoplasty. There is an incidence of thickness is 620 microns or less. outcomes and very good refractive stability What is very important in this category of that are comparable to those patients who patients is that the surgeon prevents contact have DSEK alone,” he said. of the fragments with the endothelium, and He noted that cataract surgery in patients discusses the risk of decompensation with the with Fuchs’ corneal dystrophy presents a patient,” he said. particular challenge because of the endothelial Dr Nuijts said that the soft shell technique YOUR cell loss associated with phacoemulsification. pioneered by Steve Arshinoff MD, combining CHANCE Looking at the scientific literature, Dr a dispersive and a cohesive viscoelastic, Vaddavalli said that intraocular surgery in has been shown to be particularly helpful TO a normal cornea results in an average loss in protecting the compromised corneal of between 11 per cent to 15 per cent of the endothelium in Fuchs’ dystrophy patients. SHINE! endothelial cells. In terms of phacoemulsification, Dr “This is no different in cataract surgery Nuijts said a literature survey did not in Fuchs’ dystrophy patients, with a loss of indicate any clear advantage for particular about 11 per cent to 12 per cent of endothelial nucleotomy techniques, but noted that ESCRS is looking for cells, although the absolute number of cells torsional ultrasound technology may well the best and brightest lost is probably less because you are starting offer advantages over traditional longitudinal clinical research ideas off with less cells in the first place. So if you ultrasound for these patients. do cataract surgery in a patient with Fuchs’ This was confirmed by a randomised study limited only by your dystrophy it will probably tip the balance carried out by Dr Nuijts and co-workers from a patient with no corneal oedema to one looking at the corneal thickness changes in imagination! with oedema,” he said. Fuchs' endothelial dystrophy patients who In terms of visual function, Dr Vaddavalli underwent either torsional or conventional cited a 2011 study by van de Meulen et al phacoemulsification. Funding available over that found that quality of vision is severely “We found that torsional the next fi ve years impaired in patients with Fuchs’ dystrophy phacoemulsification resulted in less US time and improves significantly after DSEK. and less cumulative dissipated energy (CDE), “The amount of light scatter in these especially in the higher grades of cataract (see patients was significantly greater than age figure above). We also saw less swelling of the ‘Expression of Interest’ forms matched controls who may or may not have a cornea at day one with torsional compared to and additional information is available at: cataract. As this light scatter can be removed longitudinal ultrasound,” he said. by performing a DSEK surgery, it seems that Dr Nuijts said it was also important to www. escrs.org the corneal endothelial changes or changes in bear in mind the disadvantages of doing a Closing Date: 13 August, 2012 the stroma might themselves cause a reduced combined procedure in such patients.

EUROTIMES | Volume 17 | Issue 7/8