This document is an interactive case presentation by Samhaa Mohammed on Fuchs corneal endothelial dystrophy (FCED). It begins by introducing a 49-year-old female patient who presents with gradual blurry vision over the past few months. Examination reveals corneal edema in the right eye. The case then goes through examining the cornea using different lighting techniques and identifying the clinical features of FCED, including edema, excrescences, and a "beaten-silver" appearance. It emphasizes the importance of suspecting FCED prior to surgery and discusses treatment options such as specular microscopy, endothelial keratoplasty procedures, and medical management depending on severity.

1. Interactive cases
(cornea odema examination)
Samhaa Mohammed Abd Elmoneim
FRCS Glasgow, Egyptian Fellowship, MSc.
Zagazig Ophthalmic Hospital
(2021)
Samhaa Mohammed

2. Samhaa Mohammed
49 years-old female
(teacher), comes to you
with gradual blurring of
vision (OU) over last few
months with fluctuation
over the day.
BCVA 6/18, 6/36
Pupil RRR OU
She is medically free
DD?
Gradual vision ↓
• Cataract
• Refractive error
• Open angle
glaucoma
• Chronic closed
angle glaucoma
• Chronic retinal
disease
• corneal diseases
• Chronic ON
diseases

3. Samhaa Mohammed
What is
important to ask
about clearly
during VA
assessment?
Near vision
She has worn near
glasses since 4
years

4. Samhaa Mohammed
Before dilatation
Lt eye, Rt eye → the same view

5. Samhaa Mohammed
Lt eye After dilatation
NC+++
Fundus free (OU)
PHACO

6. Samhaa Mohammed
OS Post operative (straight forward
phaco surgery within 10 minutes) !
Something
missed

7. Samhaa Mohammed
49 years-old female
(teacher), comes to you
with gradual blurring of
vision (OU) over last few
months with fluctuation
over the day.
BCVA 6/18, 6/36
Pupil RRR OU
She is medically free
DD?
Gradual vision ↓
• Cataract
• Refractive error
• Open angle
glaucoma
• Chronic closed
angle glaucoma
• Chronic retinal
disease
• Corneal diseases
• Chronic ON
diseases

8. Samhaa Mohammed
?
Re Examine the right eye
Oblique illumination,
magnification

9. Samhaa Mohammed
?
Re Examine the right eye
Excrescences
Beaten-silver
appearnce
Magnification

10. Samhaa Mohammed
What about normal
cornea?

11. Samhaa Mohammed
What about normal
cornea?

12. Samhaa Mohammed
What about normal
cornea?
Crystalline clear
(you see what is
behind, cornea
has no reflections
when light passes
through it)
x
More water inside
Fibers
disarrangement

13. Samhaa Mohammed
What about normal
cornea?
Thickness (thicker
in periphery)
0.56mm center
0.67 mm
periphery
x
>700mm (endoth.
Pump,
inflammation,
vessels)

14. Samhaa Mohammed
What about normal
cornea?
Contour (smooth spheric
to aspheric)
Anterior surface is
aspheric, post surface is
spheric
Normal guttata of
thickened DM in old age
(peripheral posteriorly)
x
Abnormal guttata in
FCED (central posteriorly)
Bullae anteriorly

15. Samhaa Mohammed
How to
examine
cornea?
Diffuse/ focal, direct/
indirect illumination
Narrow/ broad beam
(optical parallelepiped
section)
Retro-illumination,
specular reflection,
sclerotic scatter
Use different exam
techniques

16. Samhaa Mohammed
How to
examine
cornea?
Start
(diffuse illumination)
Clarity, thickness, contour
(Optical section, retro-
illumination, specular
reflection)
Clarity, thickness, contour
Diffuse
Focal parallelepiped
Specular
Retro
Fuchs corneal endothelial dystrophy

17. Samhaa Mohammed
What about normal
cornea?
Peripheral cornea is
thicker than central
(more collagen fibers)
Anterior stroma is more
rigid (resist hydration)
Limbus is broader
superiorly and inferiorly
Posterior surface is
spherical, anterior is
aspheric(70% of ocular
power)

18. Samhaa Mohammed
Back to our case

19. Samhaa Mohammed
FCED clinical finding

20. Samhaa Mohammed
FCED clinical finding

21. Samhaa Mohammed
Retro-illumination
FCED clinical finding

22. Samhaa Mohammed
Odema, DM folds
FCED clinical finding

23. Samhaa Mohammed
Odema, bullae → scarring
Early Dx to avoid this view
FCED clinical finding

24. Samhaa Mohammed
Your role is to suspect at this
stage before surgery → Don't
sacrifice the cornea
Excrescences

25. Samhaa Mohammed
Beaten-silver
appearance
Your role is to suspect at this
stage before surgery → Don't
sacrifice the cornea

26. Samhaa Mohammed
What should you
do if you suspect
Fuchs
endothelial
dystrophy?
Specular microscopy

27. Samhaa Mohammed
What if the
complaint is
worsened to
painful decrease
of vision?
Rupture epithelial bullae
in decompensated cornea

28. Samhaa Mohammed
From Hx: what
are the other
clues to confirm
your Dx of FCED?
Female
Middle age
Fluctuating vision (worse
in morning?)
+ve FH (AD), sporadic

29. Samhaa Mohammed
DD of FCED (clinical manifestation of
ednothelial disease/ corneal odema)
Congenital
• Glaucoma
• CHED
• PPED
• Birth trauma
Acquired
• Post-operative
(manipulation/
pseudophakic/ aphakic)
• FCED
• Hepetic keratitis (recurrent)
• Hydrops (KC → Other eye)
• ACG (epithelial)
• Traumatic/ chemical injury
• Failed graft (graft)
• ICE syndrome (unilateral)

30. Samhaa Mohammed
Prophylactic
• Less
manipulation
in cataract
surgery →
OVD → less
power→ less
time→ IOL in
bag
Non surgical Tx
• Warm Dry Air
• Hypertonic
saline, steroid
• IOP
suppressant
(avoid CAI)
(early/ mild
cases)
• Bandage CL in
bullous
keratopathy
Surgical Tx
• Endothelial
keratoplasty
(DMEK,
DSAEK, PDEK)
• DM central
stripping
• PKP (scar)
• Leave patient
blind (lack of
graft/ cost)!

31. To conclude what we learn today
• Detecting abnormal cornea requires to
adapt your eyes on normal corneal
(contour, thickness, clarity, view of its
layers)
• Detecting corneal findings requires
practicing different examination techniques
• Cornea is a very strong and transparent
structure, don't be the cause of loosing
vision by ignoring its careful examination
Samhaa Mohammed

32. Samhaa Mohammed
Thank you
Blenheim beach