Corneal Edema

Stromal and epithelial edema may occur in the immediate postoperative period.
Edema is most often caused by a combination of mechanical trauma, prolonged
surgery, inflammation and elevated intraocular pressure (IOP), resulting in acute
endothelial decompensation with an increase in corneal thickness. Small nuclear
fragments retained in the anterior chamber angle may contribute to persisten focal
corneal edema. Removing retained nuclear material may allow the corneal edema
to resolve. Chronic corneal edema from loss of endothelial cell results in bullous
keratopathy which is associated with reduced visual acuity, irritation, foreign body
sensation, ephiphora and occasional infection keratitis. Corneal edema after
cataract surgery can be controlled by the use of topical hyperosmotic agents,
topical corticosteroids and bandage contact lense. Decreased visual acuity ,
recurrent infectious keratitis and symptoms of pain are possible indications for
penetrating or endothelial keratoplasty. Bulla formation and pain associated with
bullous keratopathy may be alleviated with phototherapeutic keratectomy or
anterior stromal micropuncture, but they may recur.
Brown-McLean Syndrome
Brown Mc-Lean Syndrome is a clinical condition that may occur after cataract
surgery, consists of peripheral corenal edema with a clear central cornea. This
condition occurs most frequently following intracapsular cataract surgery. The
edema typically starts inferiorly and progresses circumferentially but spares the
central cornea. Central corneal guttae frequently appear, and punctuate brown
pigment often underlies the edematous areas.
Corneal Complications of Ultrasound
During phacoemulsification, heat may be transferred from the probe to the cornea.
The cause of such heat transfer can be an incision that is too tight to allow
adequate irrigation fluid fow along the vibrating probe, or it can be irrigation or
aspiration tubing that is occluded by an ophthalmic viscosurgical device (OVD) or
lens material. When a cornal burns occur, the heat causes contraction of the corneal
collage with subsequent distortion of the incision which may allow leakage if there
is an incision gape. These types of incision will not be self sealing and require
suturing for adequate closure.

Holding the phaco tip close to the corneal endothelium during surgery increases
the risk of endothelial cell injury and cell loss. Performing phacoemulsification or
allowing lens fragments to circulate in the anterior chamber without adequate OVD
protection can contribute to endothelial cel loss. Corneal edema may appear on the
first postoperative day.
Detachment of Descements Membrane
Detachment of Descemets membrane results in stromal swelling and epithelial
bullae localized in the area of detachment. This complication can occur when an
instruemnet or IOL is introduced through the cataor when cataract incision or when
fluid is inadvertently injected between Descemets membrane and the corneal
stroma. Small detachments may resolve spontaneously. Otherwise the use of air or
expansile gas can be use to reattach in the anterior chamber.
Corneal Melting
Keratolysis, or sterile melting of the cornea may occur following cataract
extraction. Sever melting with the postoperative use of topical nonsteroidal antiinflammatory drugs has also been reported. The melting is due in part to the
epithelial toxicity and hypoestheesia induced by these drugs. Persistent epithelial
defects accompanied by stromal dissolution require intensive treatment with
nonpreserved topical lubricants. Additional treatment modalities to encourage
epithelialization and arrest stromal melting include punctual occlusion, bandage
contact lense, tarsorrhaphy, serum eyedrops and systemic tetracylinces. The
prophylactic use of topical antibiotics must be monitored closely.
Epithelial Downgrowth
Epithelial downgrowth is a rare complication. The condition is characterized by a
sheet of epithelium growing down from the surgical incision and covering the
corneal endothelium and iris surface. Signs of epithelial downgrowth includes
elevated IOP, clumps of cells, floating in the anterior chamber, a visible
retrocorneal membrane, an abnormal iris surface and papillary distortion. The
mechanism for elevated IOP is outflow obstruction caused by growth of the
epithelial membrane over the trabecular meshwork or by epithelial cells clogging

the meshwork. Argon laser burns that applies to the membrane and iris surface
confirms the diagnosis of epithelial downgrowth.
Shallow or Flat Anterior Chamber
During ECCE or phacoemulsification, the anterior chamber may become shallow
because of inadequate of balanced salt solution into the anterior chamber, leakage
through an oversized incision, external pressure, positive vitreous pressure, or
suprachoroidal hemorrhage. Positive vitreous pressure occurs most commonly in
obese, thick-necked patients, in those with pulmonary disease, and in anxious
patients.
A flat anterior chamber during post operative period may cause permanent damage
to ocular structures. Iritovitreal or iridocapsular synechiae can also lead to
papillary block. Corneal contact with vitreous an IOL can result in endothelial cell
loss and chronic corneal edema.
Cases of shallow anterior chamber with normal or high IOP are usually the result
of papillary block, cilliary block, or suprechoroidal hemorrhage.