Eyeworld

82 | EYEWORLD | SPRING 2025 C ORNEA by Ellen Stodola Editorial Co-Director About the physicians David R. Hardten, MD Attending Surgeon Minnesota Eye Consultants Minnetonka, Minnesota Kevin M. Miller, MD Kolokotrones Chair in Ophthalmology David Geffen School of Medicine at UCLA Los Angeles, California Zeba A. Syed, MD Director of the Cornea Fellowship Program Associate Professor of Ophthalmology Wills Eye Hospital Philadelphia, Pennsylvania Handling opacified corneas when cataract surgery is needed and if they're still having problems, handle the cornea issue. The LAL works well if you've done a corneal transplant and it's clear, he said. The problem would be if you have a corneal scar, you don't want to use an LAL because UV light won't get through the scar. David R. Hardten, MD, said that if the cornea is the main issue for vision problems, he likes to try to sort that out first or at the same time as the cataract surgery. A common con- dition is Fuchs dystrophy, where a DMEK and cataract surgery combined is a common plan, he said. If the patient has a significant scar where the view is impossible, with a moderate cataract he will do a corneal transplant first and perform the cataract surgery several years later when the corneal curvature is stable. Zeba A. Syed, MD, said that slit lamp eval- uation prior to cataract surgery will generally reveal clues as to what is causing the opacified cornea. "During preoperative evaluation, it is crucial that the clinician obtain additional history or testing to ascertain possible underly- ing etiologies for the corneal opacification," she said. "Specifically, the surgeon should identify the chronology of the opacification, progres- sion, and history of prior infection. Diagnostic procedures that may be performed include O pacified corneas can present an ad- ditional challenge when preparing a patient for cataract surgery. Sever- al physicians discussed how they handle these patients and specific considerations. The challenge when someone has a cornea that's opacified and there is a cataract is deter- mining how much of the problem is the cornea and how much is the cataract, said Kevin M. Miller, MD. Sometimes you don't know, he said, adding that the order or whether you deal with both issues at the same time is important, espe- cially to the patient. "You don't want to do more surgery than you have to, and a general rule of thumb is that patients like to keep their own corneal tissue and not get someone else's." When Dr. Miller sees a patient with an opacified cornea, he finds out if it's a station- ary problem or if it's going to progress. If it's progressive, it's going to be like Fuchs dystrophy or bullous keratopathy. Cataract surgery will be another ding to help it progress and set the cornea further behind. If it's stationary, you must determine if the patient will see relatively well through the clear parts of the cornea if you leave the cornea alone and only take out the cataract. "That's a judgment call, and it's based primarily on where the opacity is with respect to the pupil," he said. If the vision is going to be limited and you don't want to subject the patient to a lot of additional risk, Dr. Miller said he generally takes out the cataract first if the cornea is stable. However, he noted that some- times it's necessary to address the cornea first. The advantage of doing the cornea proce- dure first is it stabilizes the overall situation, and you can often get a better refractive result when you perform the cataract surgery, espe- cially if you use the Light Adjustable Lens (LAL, RxSight), Dr. Miller said. "But the problem with doing it in that order is that when performing the cataract procedure, you'll damage the cor- nea with the trauma and inflammation." If the patient has a stable corneal opacity not immediately blocking the pupil, usually the best thing to do is take out the cataract and see how they do, Dr. Miller said, suggesting that you might want to give them a few months to a year, continued on page 84 Patient who had stromal rejection after DALK and got alternating mitomycin-C and bevacizumab injections for 18 months with improvement in the lipid and scar; patient had cataract surgery then a scleral lens and is now 20/20 Source: David R. Hardten, MD

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