EyeWorld Asia-Pacific March 2020 Issue

EWAP MARCH 2020 45 CORNEA he said. He also advised making a smaller capsulorhexis in combined cases and noted the importance of a clear enough cornea for safe cataract surgery. “Use aids such as trypan blue, if necessary. Dilate the pupil only with intracameral, preservative- free epinephrine so that it is easy to reduce pupil size later in the surgery when beginning the endothelial keratoplasty.” Dr. Terry said he would use a toric lens in some patients. “I use toric lenses in combined cases with DMEK, but I let the patient know it’s not quite as accurate. … They may need to have the lens rotated if their astigmatism changes after the swelling is gone,” he said. Multifocal IOLs in this subset of patients gave the surgeons pause. “I think there are situations where you could get away with a multifocal, but why?” Dr. Colby said. “If someone has a corneal disease that is significant enough to need corneal surgery … glasses independence is just not a reasonable expectation.” Dr. Chamberlain said he would consider a premium lens in a patient who has had prior DMEK. Dr. Terry bases his IOL calculations on the likelihood of a hyperopic shift, aiming for –0.8 for DMEK, –1.25 for DSAEK, and –0.5 for DSO. Dr. Colby targets her IOL calculations to 0.75–1 D myopic, knowing that DSEK would bring them closer to plano, while with DMEK or DSO she leaves them 0.5–0.75 myopic. Dr. Chamberlain said that he targets –0.5 D with DMEK and ultra-thin DSAEK. DSO can have an early myopic shift in the cornea, Dr. Chamberlain continued, adding that more long-term data is needed about how it stabilizes. None of the doctors saw a distinct benefit for using the femtosecond laser for cataract surgery in these cases. Dr. Colby said that while, theoretically, softening the lens with a femtosecond laser could reduce phaco time in the eye and thus spare endothelial cells, its benefits are not born out in peer-reviewed literature. Studies have compared conventional phaco and femtosecond laser- assisted cataract surgery in eyes with Fuchs, finding less endothelial cell loss in the FLACS group, 2,3 but a study of 207 eyes with Fuchs comparing conventional phaco and FLACS did not see a difference in corneal decompensation rates. 4 Dr. Terry also pointed out that if you were doing a combined procedure, sparing recipient endothelial cells of a cornea that is about to have an endothelial keratoplasty procedure that removes them is not a concern. “If you think you can get away with cataract surgery without having to do a transplant, I think you should use whatever technique you think causes the least amount of damage,” Dr. Terry said. The doctors provided a few final thoughts on the topic of irregular astigmatism in patients with Fuchs who need cataract surgery. Dr. Colby stressed the Sun et al. paper because it “has the potential to change the way we evaluate Fuchs patients.” Dr. Terry said it’s important to address Salzmann’s nodules and pterygia, which could be the cause of significant irregular astigmatism. Dr. Chamberlain noted increasing numbers of phakic DMEK surgeries and emphasized how DMEK grafting first can normalize the cornea and allow for better refractive IOL prediction staged at a later date. “We’ve also been surprised to see that some of our Fuchs patients are able to postpone cataract surgery for a considerable period of time because their vision improves so much from the DMEK alone,” he said. EWAP References 1. Sun SY, et al. Determining subclinical edema in Fuchs’ endothelial corneal dystrophy: Revised classification using Scheimpflug tomography for preoperative assessment. Ophthalmology. 2019;126:195– 204. 2. Fan W, et al. Femtosecond laser- assisted cataract surgery in Fuchs’ endothelial corneal dystrophy: Long- term outcomes. J Cataract Refract Surg. 2018;44:864–870. 3. Yong WWD, et al. Comparing outcomes of phacoemulsification with femtosecond laser-assisted cataract surgery in patients with Fuchs’ endothelial dystrophy. Am J Ophthalmol. 2018;196:173– 180. 4. Zhu DC, et al. Outcomes of conventional phacoemulsification versus femtosecond laser-assisted cataract surgery in eyes with Fuchs’ endothelial corneal dystrophy. J Cataract Refract Surg. 2018;44:534–540. Editors’ note: Dr. Chamberlain is associate professor of ophthalmology, Oregon Health Sciences University, Portland, Oregon. Dr. Colby is Louis Block Professor and Chair, Department of Ophthalmology and Visual Science, University of Chicago Medicine & Biological Sciences, Chicago. Dr. Terry is professor of ophthalmology, Oregon Health Sciences University, Portland, Oregon. None of the doctors declared any relevant financial interests. ADVERTISER LISTING Alcon Page 2 www.alcon.com Johnson & Johnson Vision Page 15, 16-19 www.jjvision.com Oculus Page 24 www.corneal- biomechanics.com ASCRS Page 59 www.ascrs.org APACRS Page 5, 7, 33, 36, 39, 50, 54, 56, 60 www.apacrs.org