Femtosecond lasers useful tool in certain stages of Fuchs dystrophy

Take-home message: Ophthalmologists are finding that femtosecond laser-assisted cataract surgery may be beneficial to some patients with Fuch’s dystrophy.

By Timothy A. Walline, MD, Special to Ophthalmology Times

Though cataract surgery is one of the safest procedures performed and maintains a high rate of success, patients with eye conditions in addition to cataracts can be at increased risk for complications.

With the use of femtosecond laser, ophthalmologists are finding ways to lower the risk of complications in regard to other conditions, such as Fuch’s dystrophy, while removing cataracts.

As an example, a recent cataract surgery on an 80-year-old patient with moderately severe Fuch’s dystrophy and dense nuclear cataracts used the femtosecond laser to assist in cataract removal and reduced the ultrasound time (and power) necessary to complete the procedure.

The cataract was removed 1 year ago, and there has been no need for a subsequent corneal transplant-a commonly needed postoperative surgery for patients with cataracts who also suffer from Fuch’s dystrophy.

This technology makes cataract surgery less daunting for patients with Fuch’s dystrophy. Mild cases of this condition often worsen after cataract surgery, making the success of this laser treatment encouraging.

The impact of femtosecond laser-assisted cataract surgery is notable, especially in patients who had been deferring cataract surgery due to concern of needing a subsequent corneal transplant.

Consider the symptoms

Fuch’s dystrophy is a degenerative disease affecting the corneal endothelium wherein the endothelial cells slowly die off and lose correct function. This causes fluid to build up within the cornea and leads to corneal thickening and blurred vision, two initial symptoms of Fuch’s dystrophy.

Swelling of the cornea can cause epithelial bullae or a condition known as bullous keratopathy. Patients may experience a foreign body in the affected eye or be abnormally sensitive to light and see a glare or halo when looking at lights.

The condition can be inherited, but the degree of severity can vary among family members. Fuch’s dystrophy rarely affects people under the age of 50 and is more common in women than men.

Effect of femtosecond laser

Standard cataract surgery puts patients with an advanced stage of Fuch’s dystrophy at a higher risk of corneal decompensation. Typically, using phacoemulsification alone in a dense nuclear cataract requires 10 to 15 seconds of effective phacoemulsification time.

Since using the femtosecond laser to assist in cataract nucleus softening and division, average effective phacoemulsification time has dropped to 3 to 4 seconds. This reduced time of corneal exposure to ultrasound can have an impact on recovery time for patients with Fuch’s dystrophy.

Femtosecond lasers also use a reduced level of energy, generally causing less damage to the endothelium-a main area of concern for patients with Fuch’s dystrophy.

By reducing the amount of energy used, femtosecond lasers also reduce the amount of corneal swelling, reducing the risk of a subsequent cornea transplant. The reduced level of endothelium damage and corneal swelling can also lead to more efficient healing and possibly a faster recovery time.

Case study

An 80-year-old male with Fuch’s dystrophy waited longer than average to have cataracts removed because of his condition. Last year his cataracts were successfully treated with femtosecond laser surgery (LenSx laser) without any need for postoperative corneal surgery.

The patient had been followed in the practice for more than 10 years and had developed nuclear cataracts. Despite his advanced age, the patient was a healthy, active male whose only medication was for hypertension. He had been noted to have two- to three-plus corneal guttae in 2008 and this remained relatively unchanged until his most recent examination. Standard cataract surgery would have put this patient at a higher risk of corneal decompensation due to the advanced stage of Fuch’s dystrophy.

The patient had three-plus nuclear sclerotic cataracts and best-corrected visual acuity had dropped to 20/60 in the right eye and 20/50 in the left eye.

His complete dilated exam was otherwise unremarkable, but his lifestyle had been significantly impacted by his decreased vision. The patient had problems with driving and reading. Glare made night driving nearly impossible.

The patient’s central corneal thickness preoperatively was 635 μm and IOP was consistently within the normal range. The patient elected to have surgery, which he had hoped to avoid due to his increased risk of corneal transplantation.

He had uncorrected postoperative visual acuity of 20/25, and at 1 month postoperatively corneal thickness was 649 μm.

He was pleased and subsequently underwent cataract surgery in his other eye, with equally good results. The patient has resumed driving and returned to various hobbies previously compromised by reduced vision.

Summary

The innovative advances in laser technology have opened the door for treating patients with multiple eye afflictions. In the past, cataract removal has progressed the symptoms of Fuch’s dystrophy.

However, femtosecond lasers have repeatedly proven successful in removing cataracts in patients with Fuch’s dystrophy. This treatment approach is a welcome tool in treating certain stages of Fuch’s dystrophy.

Timothy A. Walline, MD, is assistant professor of ophthalmology, University of Missouri-Kansas City School of Medicine. Dr. Walline has no financial interest in the subject matter.