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Blurred Vision despite Cataract Surgery?

A 65-year-old woman, Mrs. Gupta* came to Advanced Eye Hospital with poor vision in her left eye after Cataract Surgery (Clear corneal temporal phacoemulsification) where an artificial lens was implanted at a camp in her village two months ago. Mrs. Gupta noticed blurry vision right from the first day after surgery itself and had improved marginally since then. She had undergone cataract surgery with good results in the right eye one year earlier.

Dr. Vandana Jain, Cataract & Cornea Specialist in Navi Mumbai, who examined Mrs. Gupta, found her vision to be normal (20/20) in her right eye. However, when it came to her left eye, she could only see as much as to be able to count fingers at two feet in the left eye. The right eye examination was normal. In the left eye, the cornea was hazy and had edema (swelling). Descemets membrane (a layer of the cornea) appeared unusually thickened and also had diffuse bold folds. Mrs. Gupta’s eye pressures and corneal diameters were normal. Examination of the remaining anterior segment and adjacent tissues was normal. The posterior segment was normal on ultrasonography.

In order to know what exactly went wrong, Dr. Jain communicated with Mrs. Gupta’s operating surgeon & found that Mrs. Gupta was the tenth case of the day. Her surgery had been uneventful. No other patient that day experienced similar problems. Diffuse corneal edema with DM folds was noted on the first day after surgery. The posterior segment examination was normal. The surgeon labeled the patient with the diagnosis of TASS (Toxic anterior segment syndrome; a complication of Cataract Surgery) and the patient was treated with frequent topical steroids. No improvement was noted in the corneal status at the end of two months of follow up.

At Advanced Eye Hospital, Dr. Vandana Jain advised Mrs. Gupta to continue with her topical steroids. Over the next two months, no improvement was noted in the corneal status and hence, Mrs. Gupta underwent DSEK (cornea transplantation) in her left eye.  

One day after DSEK, the patient’s visual acuity had improved from count fingers to 20/200, and at the last follow up, three months after DSEK the best spectacle-corrected visual acuity (BSCVA) was 20/25.

Take Home Message:

Transplantation of the posterior layers of the cornea to treat endothelial dysfunction has gained interest as an alternative to penetrating keratoplasty.

DSEK has several advantages over PKP:

· No sutures are required for the transplant, hence the concerns about suture removal and late wound dehiscence (a surgical complication in which a wound ruptures along surgical suture) after suture removal are alleviated;

· Visual recovery occurs faster with minimal fluctuations during the healing process; and the refractive status of the eye before the surgery is maintained.

· Also there is a possible added advantage of reduction in the endothelial rejection rate due to the absence of epithelium, minimization of stromal tissue, lack of sutures and reduction of concern over wound strength thereby permitting surgeons to use topical steroids for a longer periods after DSEK

In summary, this report highlights that irreversible corneal edema due to TASS can be successfully treated with DSEK even when a fibrous membrane behind descement’s membrane is present.  

*name changed to protect privacy