What are the treatment options for edema?

Treatment of Edema

Treatment of edema must be tailored to the specific underlying cause, with diuretics reserved for systemic causes and targeted therapies for localized conditions.

Ophthalmologic Edema

Corneal Edema

• Topical sodium chloride 5% solution or ointment is first-line treatment, working through hyperosmotic effect to reduce corneal edema 1, 2
• Hair dryer use provides temporary symptomatic relief for both primary and secondary corneal edema 1, 2
• Reduce intraocular pressure when elevated or in the upper normal range 1
• Avoid topical carbonic anhydrase inhibitors as first-line therapy when endothelial dysfunction exists, as they interfere with the endothelial pump 1, 2
• Control inflammation with topical corticosteroids after excluding infection 2

Bandage Contact Lens for Symptomatic Corneal Edema

• Use thin, high water content lenses with high oxygen diffusion coefficients (Dk levels) for microcystic or bullous epithelial disease 3, 2
• Apply prophylactic broad-spectrum topical antibiotics to reduce infection risk 3, 2
• Limit duration to short-term use; exchange lenses periodically if long-term use necessary (maximum one month per lens) 3, 2
• Educate patients about infectious keratitis risk and need for immediate contact if redness, pain, or photophobia develops 3, 2

Surgical Options for Refractory Corneal Edema

• Phototherapeutic keratectomy (PTK) with ablations ≥100 μm provides pain relief through sub-basal nerve plexus ablation, though does not provide long-term visual rehabilitation 3, 2
• Conjunctival flap achieves rapid healing and comfort when visual rehabilitation is not the goal 3, 2
• Keratoplasty procedures for definitive treatment when visual potential exists 2

Diabetic Macular Edema

First-Line Treatment

• Intravitreal anti-VEGF agents (ranibizumab, aflibercept, or bevacizumab) are first-line treatment for center-involved diabetic macular edema with vision impairment 3, 1
• Administer near-monthly injections during the first 12 months, with fewer injections in subsequent years 3
• Aflibercept provides superior vision outcomes compared to bevacizumab when eyes have moderate visual impairment (vision 20/50 or worse) 3
• For eyes with good vision (20/25 or better) despite diabetic macular edema, close monitoring with deferred anti-VEGF therapy provides similar 2-year outcomes to immediate treatment 3

Second-Line and Alternative Treatments

• Macular focal/grid photocoagulation or intravitreal corticosteroids are reasonable for persistent diabetic macular edema despite anti-VEGF therapy 3, 1
• Both therapies are also reasonable first-line approaches for patients who are not candidates for anti-VEGF treatment (e.g., pregnancy) 3
• Focal/grid laser can be added initially or deferred until edema persists after anti-VEGF injection 1

Systemic Edema

Heart Failure-Related Edema

• Spironolactone is indicated for NYHA Class III-IV heart failure with reduced ejection fraction to increase survival, manage edema, and reduce hospitalization 4
• Initiate at 25 mg once daily in patients with serum potassium ≤5.0 mEq/L and eGFR >50 mL/min/1.73 m² 4
• May increase to 50 mg once daily if tolerated; reduce to 25 mg every other day if hyperkalemia develops 4
• For eGFR 30-50 mL/min/1.73 m², consider initiating at 25 mg every other day due to hyperkalemia risk 4
• Loop diuretics are often used alone or in combination for fluid management 5

Cirrhosis-Related Edema and Ascites

• Initiate spironolactone therapy in hospital setting with slow titration for cirrhotic patients 4
• Recommended initial dose is 100 mg daily (single or divided doses), ranging from 25-200 mg daily 4
• When used as sole diuretic agent, administer for at least five days before dose escalation 4
• Paracentesis combined with spironolactone for ascites management 5

Nephrotic Syndrome-Related Edema

• Spironolactone is indicated when underlying disease treatment, fluid/sodium restriction, and other diuretics produce inadequate response 4
• Particularly useful when other diuretics have caused hypokalemia 4

Hypertension-Related Edema

• Spironolactone indicated as add-on therapy at 25-100 mg daily (single or divided doses) 4
• Titrate at two-week intervals; doses >100 mg/day generally provide no additional blood pressure reduction 4
• Dihydropyridine calcium channel blocker-induced edema can be treated with ACE inhibitor or angiotensin-receptor blocker 5

Cerebral Edema

• Free water restriction, avoid excessive glucose administration, minimize hypoxemia and hypercapnia, treat hyperthermia 1
• Mannitol 0.25-0.5 g/kg IV over 20 minutes reduces intracranial pressure; can be administered every 6 hours (usual maximum 2 g/kg) 1
• Hyperventilation in intubated patients induces cerebral vasoconstriction, reducing cerebral blood volume and intracranial pressure 1

General Principles

Conservative Measures

• Sodium restriction is fundamental for all systemic causes of edema 5, 6
• Leg elevation helpful for lower extremity edema 5
• Compression therapy effective for most causes of edema, particularly chronic venous insufficiency 6
• Range-of-motion exercises beneficial for lymphedema 5

Diagnostic Approach

• For acute unilateral lower-extremity edema, immediately evaluate for deep venous thrombosis with d-dimer or compression ultrasonography 6
• For chronic bilateral lower-extremity edema, obtain duplex ultrasonography with reflux to diagnose chronic venous insufficiency 6
• Basic metabolic panel, liver function tests, thyroid function, brain natriuretic peptide, and urine protein/creatinine ratio guide systemic evaluation 6

Important Caveats

• Diuretics should only be used for systemic causes of edema, not for localized conditions 6
• Spironolactone can be taken with or without food but should be taken consistently with respect to food 4
• Monitor for hyperkalemia when using spironolactone, particularly in patients with reduced renal function 4