What are the clinical recommendations for patients with reduced endothelial cell density and corneal thinning?

From the Guidelines

Patients with reduced endothelial cell density and corneal thinning should be managed with a stepwise approach focusing on both preservation of remaining endothelial cells and addressing corneal thinning, as outlined in the most recent guidelines from 2024 1.

Initial Management

Initial management includes:

• Preservative-free lubricating eye drops 4-6 times daily to maintain ocular surface integrity and reduce mechanical stress
• Hypertonic saline drops (5% sodium chloride) to manage corneal edema if present
• Avoiding eye rubbing and using protective eyewear during activities that risk ocular trauma Regular monitoring with specular microscopy every 3-6 months is recommended to track endothelial cell loss progression 1.

Progressive Cases

For progressive cases, consider:

• Bandage contact lenses for mechanical protection
• Endothelial keratoplasty procedures like DSAEK or DMEK when endothelial cell density falls below 500-700 cells/mm² If corneal thinning is severe (less than 400 microns centrally), collagen crosslinking may stabilize the cornea, while scleral contact lenses can provide both visual rehabilitation and mechanical support 1.

Key Considerations

Key considerations in managing patients with reduced endothelial cell density and corneal thinning include:

• Lowering intraocular pressure (IOP) if elevated or at the upper end of the normal range
• Avoiding prostaglandin analogues if inflammation is a possible contributing factor
• Using topical carbonic anhydrase inhibitors with caution if endothelial dysfunction is a possible contributing factor
• Controlling inflammation with topical corticosteroids if present 1.

Surgical Options

Surgical options for corneal edema, including penetrating keratoplasty (PK), Descemet stripping automated endothelial keratoplasty (DSAEK), and Descemet membrane endothelial keratoplasty (DMEK), have varying outcomes in terms of dislocation rate, wound dehiscence, donor failure, and rejection rate 1. However, the most recent guidelines from 2024 1 provide the most up-to-date recommendations for managing patients with reduced endothelial cell density and corneal thinning.

From the FDA Drug Label

WARNINGS ... In those diseases causing thinning of the cornea or sclera, perforations have been known to occur with the use of topical steroids. The clinical recommendations for patients with reduced endothelial cell density and corneal thinning are to use corticosteroids with caution, as prolonged use may increase the risk of perforations in diseases that cause corneal thinning 2.

• Key considerations:
  • Caution with corticosteroid use in patients with corneal thinning
  • Risk of perforations with prolonged corticosteroid use
  • Monitor for signs of infection or exacerbation of existing conditions

From the Research

Clinical Recommendations for Reduced Endothelial Cell Density and Corneal Thinning

• Patients with reduced endothelial cell density and corneal thinning require careful management to prevent further complications, such as corneal edema and reduced visual acuity 3.
• Monitoring of endothelial cells can be performed clinically or with specular microscopy, and in cases of significant compromise, endothelial cells can be transplanted by various endothelial keratoplasty techniques 4.
• The etiology of endothelial dysfunction is extensive and may be related to systemic diseases, eye diseases, or therapeutic ophthalmological interventions, highlighting the need for a comprehensive diagnostic approach 3, 5.
• Corneal endothelial cell density (ECD) is significantly lower in patients with dry eye disease (DED) compared to an age-matched control group, and there is a correlation between corneal ECD and dry eye severity parameters 6.
• Contact lens wear can cause hypoxia and hypercapnia, leading to changes in the corneal epithelium, stroma, and endothelium, including decreased endothelial cell density and corneal thinning 7.
• Management strategies for patients with reduced endothelial cell density and corneal thinning may include:
  • Regular monitoring of endothelial cell density and corneal thickness
  • Treatment of underlying systemic or eye diseases
  • Avoidance of contact lens wear or use of high-oxygen-permeable contact lenses
  • Endothelial keratoplasty techniques in cases of significant compromise
  • Rehabilitation and regeneration therapies, which are currently being developed 4