Managing clinical conditions: Fuch’s dystrophy

Philadelphia-Paul Karpecki, OD, FAAO, and Jill Autry, OD, RPh, shared clinical management pearls with attendees at the American Optometric Association’s Optometry’s Meeting.

In the past three years, more ODs bought specular microscopes than ophthalmologists, says Dr. Karpecki. Some 78 percent of ODs have pachymeters in the office as well. These instruments allow ODs to help manage certain clinical conditions.

Consider these four clinical stages of Fuch’s dystrophy before referring a patient with this condition.

• Guttata

• Stroma edema with decreased vision, worse in the morning

• Epithelium edema, including pain with ruptured bullae and further decrease in vision

• Corneal scarring

"If the epithelium can't pump, that's when we have problems," says Dr. Autry.

Says Dr. Karpecki: It’s time to start educating the patient about future surgical options, such as transplant, with these clinical signs:

• Morning blur that lasts a significant amount of time, such as >30 minutes

• Pachymeters over 600 µm in a patient who previously had normal (~550 µm) corneal thickness

• Specular microscopy signs

• First cataract surgery resulted in endothelial decompensation

Treatment for Fuch’s dystrophy includes:

• Observation

• Muro 128 5% solution/ung; a generic is available at half the price of brand; order online for better pricing

• FreshKote

110 mm Hg oncotic pressure pull

More comfortable daytime drop

• Lowering IOP may reduce stromal and epithelial edema

• Avoid carbonic anhyrase inhibor (CAI) medications because will further impede pumping action

• Bandage contact lens pm

Dr. Autry suggested trying a brand name medication if the results are acceptable. “If you're not hitting what you expect with a generic medication, try something else,” she says. “The eye is so good at keeping things off of it, even a small change in pH could make a difference.”

An attendee asked Drs. Autry and Karpecki if a scleral lens would be a good option for Fuch’s patient. Good question, says Dr. Karpecki. “Some people believe the one contraindication to a scleral is a compromised cornea. With newer lenses, it may not be the case. It's still a debatable question.”ODT