Cataract surgery in the presence of corneal disease presents multiple challenges, from determining whether symptoms are lenticular or corneal in origin, to decisions regarding timing of surgery, intraocular lens (IOL) power calculation, IOL selection, surgical technique and perioperative care. Realistic expectation setting is central and requires careful assessment and detailed discussion of potential outcomes.
This article discusses practical strategies applicable across a range of corneal conditions to assist the non-corneal specialist managing these cases.
Management of the ocular surface
Compromised ocular surface, dry eyes and meibomian gland dysfunction are common across a range of corneal conditions. It is important to assess and optimise the ocular surface carefully prior to cataract surgery. An unstable surface reduces the accuracy and repeatability of biometry measurements increasing the risk of refractive surprise [1,2]. It may also disproportionately contribute to visual symptoms in a compromised cornea, adding to the difficulty in assessing cataract significance.
Cataract surgery induces ocular surface inflammation and can exacerbate dry eyes, increasing the risk of epithelial breakdown, delayed healing and, rarely, corneal melt [3,4]. Patients should be counselled regarding transient worsening of dry eye symptoms and possible flare of recurrent erosions.
Postoperatively, patients should be managed with preservative-free drops, including lubricants and steroids. Although not strongly evidence based, many surgeons employ a short course (3–5 days) of preservative-free prophylactic antibiotics in high-risk corneas. Topical non-steroidal anti-inflammatory drugs should be used with caution, particularly in patients with autoimmune diseases such as rheumatoid arthritis, where an increased risk of corneal melt has been reported [5].
Ensuring stability of the corneal condition
The cornea should be demonstrably stable before proceeding with cataract surgery. This is particularly important in ectatic and inflammatory conditions. Ectatic disorders such as keratoconus and pellucid marginal degeneration should be monitored for stability. Corneal collagen cross-linking is effective in halting progression and should be performed prior to cataract surgery where progression is documented [6,7]. Intracorneal ring segments can be used to regularise the corneal shape before surgery.
Progressive pterygium or visually significant calcific band keratopathy should be treated prior to cataract surgery if they interfere with keratometry. A stabilisation period of approximately six months following corneal intervention is generally recommended.
In infectious or inflammatory corneal diseases such as herpes simplex or zoster keratitis, surgery should only be undertaken once the eye is quiet for at least 3–6 months [8]. In autoimmune conditions such as mucous membrane pemphigoid or Behcet’s disease, cataract surgery should be deferred until inflammation has been well controlled for a sustained period, often in collaboration with medical ophthalmology or rheumatology colleagues [9–12].
Assessing visual significance
Assessing the visual significance of cataract in a patient with corneal disease can be challenging. Where the corneal condition is longstanding and stable (e.g. keratoconus in an older patient) and the patient has previously achieved good vision with spectacles or contact lenses, recent deterioration is more likely due to cataract progression.
"Several small modifications to surgical technique can facilitate cataract surgery in corneal disease"
In contrast, when the corneal disease is recent or unstable, the relative contribution of cataract may be more difficult to determine. A diagnostically rigid contact lens trial can be useful. Significant improvement suggests corneal irregularity rather than cataract as the dominant cause of visual symptoms.
Sequencing of surgery
The sequencing of cataract and corneal surgery depends on the relative visual significance of the cataract and the adequacy of intraoperative visualisation through the cornea. Where corneal opacity is sufficient to compromise surgical safety, keratoplasty followed by cataract surgery, or a combined ‘triple’ procedure may be required.
In Fuchs endothelial corneal dystrophy, cataract surgery alone may be appropriate in the absence of corneal oedema or symptoms of early endothelial decompensation, such as morning blur. Patients should be counselled regarding the risk of postoperative corneal decompensation and the potential need for endothelial keratoplasty – cataract surgery can be undertaken outside a corneal subspecialist setting in such cases.
Where there is evidence of early endothelial failure, combined cataract surgery with endothelial keratoplasty is preferred. A preoperative central corneal thickness of >640 microns has been suggested as a threshold for combined surgery [13]. However, in routine clinical practice, the presence or absence of early corneal oedema and associated symptoms often guides decision-making more than pachymetry or specular microscopy.
In eyes at risk of future endothelial keratoplasty, a mildly myopic refractive outcome (approximately -0.50 to 0.75 dioptres) is recommended to offset the predictable hyperopic shift associated with endothelial transplantation [14]. Where the cornea is stable and visual quality was previously acceptable, cataract surgery alone is usually sufficient [15].
Intraocular lens power calculation
Intraocular lens power calculation is often challenging in corneal disease. Some general principles apply across the spectrum of corneal conditions.
The ocular surface should be optimised as much as possible prior to measurements [1,2]. Biometry derived keratometry values (Ks) should be compared to tomography Ks to ensure accuracy. Axial length measurements are usually unaffected by corneal pathology.
Where available, disease specific formulas should be used (such as for post-refractive surgery eyes or keratoconus). In keratoconus, the keratoconus-specific formulae (Barrett True-K, Kane Keratoconus) have been shown to perform better than generic formulae [16,17]. These are readily available through the ESCRS web-based IOL calculator.
In severe unilateral corneal disease, fellow-eye keratometry may be used with axial length from the affected eye. In advanced bilateral disease, use of standard keratometry values may be appropriate, particularly if future corneal surgery is anticipated.
Targeting low myopia is generally advisable, as hypermetropic surprises are poorly tolerated and also more difficult to manage [14,18].
Choice of intraocular lens
A conservative approach usually yields the best results. In a compromised cornea, the best optical quality is achieved with a monofocal IOL. Toric lenses may be appropriate where astigmatism is predominantly regular, the patient has history of good spectacle corrected vision, the cornea is stable, and no future corneal surgery is anticipated. Toric IOLs are generally not suitable in rigid gas permeable (RGP) contact lens wearers who intend to continue RGP wear after surgery, or those likely to undergo keratoplasty.
Extended depth of focus lenses can be considered in certain carefully selected cases while multifocal IOLs are rarely appropriate in corneal disease. Hydrophilic IOLs should be avoided in endothelial disease due to the risk of opacification following intraocular gas exposure [19-22].
Perioperative care
Perioperative management includes ocular surface optimisation, antiviral prophylaxis in herpetic disease and topical or systemic steroids or immunosuppression in inflammatory conditions. In selected patients with systemic autoimmune disease, intraoperative intravenous methylprednisolone is used to reduce the risk of postoperative corneal melt.
Surgical technique
Several small modifications to surgical technique can facilitate cataract surgery in corneal disease. Use of 2% hydroxypropyl methylcellulose on the corneal surface improves visualisation and reduces epithelial desiccation [23]. In moderate-to-severe corneal oedema, epithelial debridement can improve the intraoperative view.
"Cataract surgery in the presence of corneal disease can be undertaken safely with relatively small modifications to standard surgical planning and perioperative care"
A continuous curvilinear capsulorhexis is often possible in the presence of significant corneal opacity. Leaving trypan blue in the anterior chamber for at least 30 seconds improves staining quality. The capsulorhexis is started in an area with good view and re-gripped prior to moving under areas with poor view. Moving the eye around or using a light pipe at the limbus can also help enhance visualisation.
In endothelial disease or shallow anterior chambers, endothelial protection using the soft-shell technique is recommended [24]. Incision placement requires careful planning in eyes with prior radial keratotomy, grafts, scarring or peripheral thinning. In ocular cicatricial pemphigoid, clear corneal incisions that avoid conjunctival disturbance are preferred [11].
Postoperative treatment
The general principles of postoperative management in corneal disease include reducing preservative exposure, use of lubricants and careful follow-up until epithelial healing is complete.
In eyes with previous herpes simplex keratitis, oral antiviral prophylaxis is commonly used. A UK survey reported that 58% of surgeons started oral antiviral prophylaxis preoperatively – usually Acyclovir 400mg twice daily for seven days, with variable duration postoperatively [8]. Continuing oral antiviral prophylaxis for approximately four weeks after surgery, or until topical corticosteroids are discontinued, is a pragmatic approach. Most surgeons do not alter their standard steroid regime following cataract surgery [8].
A short course of systemic steroids may be considered in patients at risk of corneal melt [5]. A course of Doxycycline may be beneficial in patients with significant ocular surface disease or meibomian gland dysfunction [25]. Careful IOP monitoring is essential, particularly if there is history of steroid responsiveness.
In summary, cataract surgery in the presence of corneal disease can be undertaken safely with relatively small modifications to standard surgical planning and perioperative care. In a number of situations, surgery may be appropriately performed by non-corneal specialists, including eyes with stable pterygium, Fuchs endothelial corneal dystrophy prior to the development of corneal oedema, corneal scarring that permits adequate intraoperative visualisation, and long-standing mild or subclinical keratoconus. Referral to a corneal specialist should be considered where corneal disease limits biometry reliability, compromises intraoperative visualisation, is progressive or inflammatory in nature, or where there is a significant likelihood of requiring corneal transplantation in the medium term.
References
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Declaration of competing interests: None declared.
