Management of Thickened Corneal Endothelium
For thickened corneal endothelium, the primary management approach is referral to an ophthalmologist with expertise in corneal disorders, followed by appropriate medical therapy and possible surgical intervention with endothelial keratoplasty when indicated. 1
Diagnosis and Assessment
When a thickened endothelium is identified, thorough evaluation is essential:
- Slit-lamp biomicroscopy to assess corneal clarity and health
- Corneal pachymetry to measure corneal thickness (particularly valuable when baseline data is available)
- Serial corneal tomography to track corneal thickness over time and manage astigmatism
- Visual acuity measurement to determine functional impact
- External examination to identify associated conditions
Medical Management
Initial management focuses on controlling corneal edema and maintaining corneal health:
- Topical hypertonic saline solutions to reduce corneal edema
- Bandage contact lenses for cases with persistent epithelial defects
- Topical antibiotics to prevent secondary bacterial infection when epithelial defects are present
- Regular monitoring every 3-6 months to assess for progression 1
Surgical Management
When medical management fails to control symptoms or when visual function is significantly affected, surgical intervention should be considered:
Endothelial Keratoplasty (EK)
This has become the preferred surgical approach for endothelial dysfunction due to:
- Rapid visual recovery
- Greater optical predictability (both astigmatic and refractive)
- Smaller and more stable wounds
- Decreased risk of graft rejection compared to penetrating keratoplasty 1
Types of Endothelial Keratoplasty:
DMEK (Descemet Membrane Endothelial Keratoplasty)
- Preferred for standard endothelial failure with good anterior chamber visibility
- Offers better visual outcomes
- Use of "S" stamp for orientation and SF6 gas has reduced complications 1
DSAEK (Descemet Stripping Automated Endothelial Keratoplasty)
- Better option for eyes with decreased anterior chamber visibility
- Appropriate for complex situations (previous glaucoma surgery, iris defects)
- Ultrathin DSAEK (<100 μm) may provide better visual recovery 1
Post-Surgical Management
After surgical intervention, careful monitoring is essential:
- Regular slit-lamp examinations to assess corneal clarity and health
- Monitor for signs of rejection (redness, light sensitivity, vision changes, pain)
- Topical corticosteroids to prevent and treat graft rejection
- IOP monitoring to detect corticosteroid-induced pressure elevation
- Patient education about warning signs requiring immediate attention 1
Special Considerations
Graft Rejection Management
If endothelial rejection occurs (evidenced by keratic precipitates, rejection line, anterior chamber reaction):
- Intensive topical corticosteroids
- Possible oral corticosteroids
- Subconjunctival or sub-Tenon corticosteroid injections in severe cases 1
Emerging Approaches
- Primary descemetorhexis with or without topical Rho kinase inhibitors to facilitate endothelial health 1
- Ex vivo expansion of injectable endothelial cells (investigational) 1
When to Refer
Prompt referral to a corneal specialist is warranted when:
- Visual loss occurs
- Functional vision deteriorates
- Disease shows progression
- Early onset of condition is observed 1
The management of thickened endothelium requires specialized care to prevent irreversible vision loss and maintain optimal corneal health and function.