When should patients with Fuchs' dystrophy have cataract surgery or corneal transplantation

A diagnosis of Fuchs' dystrophy inevitably leads to some anxiety. Fuchs' is a condition that progresses and gradually leads to deterioration in vision due to waterlogging of the cornea. Fuchs' dystrophy is a diagnosis that is typically made in patients over 50, although younger people may also be diagnosed. As patients are older at the time of diagnosis there may also be cataract present. So, should patients have cataract surgery alone with a transplant some time later, or should they have a combined cataract operation and corneal transplant?

The time to have any surgery is if the cataract or Fuchs' dystrophy is affecting your vision and lifestyle. Any intraocular surgery such as cataract surgery will further reduce the number of endothelial corneal cells in a patient with Fuchs' dystrophy. If the  Fuchs' dystrophy is still in its early stages and there is sufficient endothelial cell reserve, the patient can proceed with cataract surgery alone. The operating surgeon should use a modified 'soft shell' technique during cataract surgery to minimise damage to remaining endothelial cells. An endothelial cell scan should be part of the pre-operative assessment and will inform the surgeon of whether cataract surgery alone without corneal transplantation can be attempted.

Endothelial cell scan

Endothelial cell scan

Patients who have a low endothelial cell count and who have diurnal changes in their vision and evidence of corneal swelling are likely to be worse after cataract surgery alone. These patients should have combined cataract surgery and corneal transplantation. Alternatively, some surgeons may wish to separate the cataract surgery from the transplant and perform the latter a month or so later. My personal preference is to combine the two procedures.

What type of corneal transplant should a patient with Fuchs' dystrophy have? The current gold standard is the DMEK operation which is a pure endothelial cell transplant. This surgery is performed through a keyhole incision and has a very low rejection rate of less than 1%. An alternative technique is the DSAEK technique which transplants a thin layer of corneal tissue from a donor to replace the diseased endothelial cells of the Fuchs' patient. This is also performed through a small incision. Full thickness corneal transplants (penetrating keratoplasty) are no longer considered the standard of care for Fuchs' dystrophy and typically have a long recovery period, structurally weakens the eye, has unpredictable astigmatism and has a higher rejection rate. 

Corneal surgeons trained in modern techniques should be able to offer patients DMEK and DSAEK surgery.

Romesh Angunawela - Consultant Eye Surgeon

Posted on May 18, 2016 .