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FALL 2024 | EYEWORLD | 67 C multifocal IOL, so these are contraindicated in combined procedures. 7 2. For patients who want a multifocal lens and have cataract and Fuchs, Dr. Price will do DMEK first and put the multifocal lens in 2–3 months later. With this staged ap- proach, you need to do the cataract second because if you do the cataract first, the pa- tient will still have irregularity from Fuchs that throws off the biometry used to select the IOL power. 8 3. The last option he mentioned was DMEK combined with implantation of a Light Ad- justable Lens (LAL, RxSight). The LAL is ap- proved for 2 D of postoperative adjustment, so that almost covers the range of error, Dr. Price said. It gives you a good chance of getting most patients close to plano. He uses the LAL for a quarter of patients in whom he does combined cases and has published on this approach. 9 It takes longer for refractions to stabilize after DMEK than after standard cataract surgery, so he is slower to proceed with lens adjustment and lock-in after combined procedures. In cases of visually significant cataract with moderate to severe Fuchs or with signif- icant corneal edema, Dr. Syed said she often combines cataract surgery with an endothelial keratoplasty. "The benefit of this approach is that it saves the patient from requiring a second surgery." Intraoperatively, these cases may be challenging due to reduced visualization through an edematous cornea. "I find epithelial debridement to improve the view significantly in cases of epithelial edema," Dr. Syed said. "Keratometry changes after endothelial kera- toplasty can be highly unpredictable, particu- larly in those with superficial edema. Hence, I counsel these patients on the likely need for spectacle correction after combined endothelial keratoplasty and cataract surgery." Dr. Syed will also use staged endothelial keratoplasty followed by cataract surgery, par- ticularly when patients have higher refractive expectations or needs. "This approach is helpful in individuals who desire a toric or presbyopia- correcting IOL," she said. "Of course, the risk in this case is further endothelial cell loss in the graft secondary to cataract surgery." You might not carry this magazine with you everywhere, but EyeWorld is always at your fingertips. Full issues Online Exclusives Weekly updates WWW.EYEWORLD.ORG

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