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Cover Focus | Sept/Oct '18

Quality Over Quantity

It was my second day of private practice, and I was so excited to start seeing my own patients. My first patient of the day was a very nice woman who was referred to me for an endothelial transplant. She had a history of complicated cataract surgery, and she subsequently developed a retinal detachment requiring repair and lens repositioning. Since her last surgery, her biggest complaint was “darkness” in the left eye when compared with the right eye.

My colleague referred the patient to me for “pigment on the endothelium,” which he believed was causing contrast sensitivity issues in her right eye. Being so early in my practice, I had never seen pigmentation alone (without guttae or endothelial folds) cause a visual complaint. Previously, I had seen it in a Krukenberg spindle in patients diagnosed with pigment dispersion, and those patients were usually asymptomatic.

Upon examination, the patient’s BCVA was 20/20 OD and 20/50 OS. Her pachymetry measurements were 581 μm OD and 587 μm OS, and her endothelial cell counts were 2,436 cells/mm2 OD and 1,526 cells/mm2 OS. Slit-lamp examination of the right eye was normal. Upon slit-lamp examination of the left eye, I discovered endothelial pigmentation in a circular pattern centrally. Her retina was attached, and her macula was mottled.

At the initial consultation, I explained to the patient that I was uncertain whether Descemet stripping endothelial keratoplasty (DSEK) would benefit her, given her significant retinal history, but that we could consider it in the future. Being so early in my practice, I was unsure that doing surgery on someone with such an unpredictable outcome was a good idea. The patient was not too keen on undergoing an additional procedure either.

We decided to observe, and I saw the patient every 6 months for the next 2 years. After 2 years, despite no change in her visual acuity, the patient’s contrast sensitivity issues had worsened and she started to inquire about surgery. We decided to proceed with DSEK, knowing that her vision may or may not improve. After surgery, her vision improved to 20/30, and she was ecstatic. On postoperative day 1, the patient told me how much she appreciated my conservative and honest approach to her case. She liked that I didn’t “force” her into surgery and that I was honest about the unpredictable outcome.


This case changed the way I approach patients with endothelial disease. When I was in training, I was taught to be cautious about recommending an endothelial transplant unless there was significant edema or a decline in visual acuity on examination. Since this experience, I have found it extremely important to talk to the patient and gain a better understanding of what the exact issue is with his or her vision (contrast, sensitivity, etc.). This is the way I approach refractive patients, and these patients should not be treated any differently.

Overall, this case taught me that it is the quality of vision we should strive to improve, not the quantity. Now that Descemet membrane endothelial keratoplasty is becoming standard of care for straightforward endothelial disease, we need to start determining quality of vision in addition to understanding the quantity and objective measures. Patients with 20/25 visual acuity who would have previously been told they were not candidates for an endothelial transplant can actually benefit significantly from surgery. If the procedure does not improve BCVA but instead improves quality of vision, this may, in turn, improve lifestyle practices. Patients continue to come in with higher expectations, and it is important for cornea specialists to look at the big picture and not just at the objective data.

Heather M. Weissman, MD