By Dr. Hemali Kanabar | July 9, 2025
ποΈ What is Fuchs Endothelial Dystrophy?
Fuchs Endothelial Dystrophy (FED) is a progressive, bilateral, and typically asymmetric corneal dystrophy that affects the endothelial layer of the cornea. It leads to corneal decompensation and visual loss due to fluid accumulation and corneal thickening.
𧬠Pathophysiology
In FED, the corneal endothelial cells (which pump out excess fluid) progressively degenerate. This leads to:
- Formation of guttae (excrescences on Descemet’s membrane)
- Loss of endothelial cell density
- Stromal and epithelial oedema
- Painful bullae in advanced stages
π Clinical Features
| Stage | Findings |
|---|---|
| Early | Guttae seen on specular reflection, minimal symptoms |
| Moderate | Decreased vision (especially in morning), corneal thickening |
| Advanced | Stromal oedema, epithelial bullae, painful vision loss |
π οΈ Tip: Use a slit-lamp with specular reflection or confocal microscopy to detect early guttae.
π¬ Diagnosis
- Slit-lamp exam: Guttae, stromal haze, epithelial bullae
- Specular microscopy: Reduced endothelial cell count
- Pachymetry: Corneal thickening (>640 ΞΌm may indicate decompensation)
- OCT of anterior segment: Helps assess corneal layers
π Disease Progression and Cataract Coexistence
FED often presents in older adults, and many patients also have cataracts. This creates a management dilemma: Which to treat first β the cornea or the lens?
Hereβs a simplified management approach
π§ Management Strategy in Patients with FED and Cataract
| Clinical Scenario | Suggested Management |
|---|---|
| No cataract + mild corneal oedema | π’ Conservative medical management (hypertonic saline, lubricants) |
| Dense cataract + severe corneal oedema | π Triple procedure (phacoemulsification + IOL + endothelial keratoplasty) |
| No cataract + severe corneal oedema | π Keratoplasty (DMEK/DSAEK) first β cataract surgery later if needed |
| Dense cataract + clear cornea | ποΈ Cataract extraction first β keratoplasty only if decompensation occurs |
π Surgical Options
- DMEK (Descemet Membrane Endothelial Keratoplasty): Replaces only Descemet’s membrane and endothelium. Quicker recovery, excellent outcomes.
- DSAEK (Descemet Stripping Automated Endothelial Keratoplasty): Easier technique, but more stromal interface haze.
- Triple Procedure: Phacoemulsification + IOL + DMEK/DSAEK in the same sitting.
β οΈ Postoperative Considerations
- Monitor intraocular pressure
- Watch for graft dislocation
- Long-term steroid therapy may be needed
- Visual recovery is typically excellent if macula is healthy
π§Ύ FRCOphth Exam Tip
In OSCEs or viva, always assess the extent of corneal oedema and coexisting cataract. Be ready to justify your decision-making in sequential vs. combined approaches.
π Summary
- FED is a progressive endothelial dystrophy leading to corneal oedema.
- The presence and severity of cataract and corneal changes determine management.
- Triple procedure is ideal for advanced cases with coexisting cataract and oedema.
- DMEK is the gold standard for endothelial replacement.