29 EyeWorld Asia-Pacific | December 2024 Intraoperative considerations Dr. Venkateswaran said that excellent wound construction is critical, as corneal elasticity in ectatic eyes can affect wound healing. She said to place a suture if the wound does not seal or if there are any concerns about wound closure. Trypan blue can be used to stain the anterior capsule to improve visualization. “Often, these eyes can have deeper anterior chambers; use low flow settings to reduce chamber fluctuations,” she said. While Dr. Pasricha said that cataract surgery in these patients is generally standard, there are a couple of things that may occur. First, it’s possible that the ectasia is so severe that it will distort the intraoperative view through the microscope. Putting a layer of viscoelastic on the cornea can help with this. It smooths it out and gives better optics, he said. A lot of these patients, in addition to having a thin cone, have a thin periphery of their corneas, he said, so when you make the incisions, oftentimes you want to aim on the longer end. He has a low threshold to place a suture if the wound is not closing well. “If you’re aware ahead of time and have a severe case, it’s always safer to plan for a scleral tunnel incision because you’ll have less concern about the wound leaking postop,” Dr. Pasricha said. Other considerations While Dr. Venkateswaran and Dr. Pasricha said that cataract surgery will not directly exacerbate keratoconus, there are some things to consider. Dr. Venkateswaran said it’s important to ensure the keratoconus is stable prior to proceeding with cataract surgery. If corneal ectasia or scarring is severe, the patient may need staged penetrating keratoplasty or DALK prior to cataract surgery. Rarely, keratoconus patients can have concomitant Fuchs dystrophy/guttae, and some cases may require an endothelial keratoplasty. “Progressive keratoconus that is missed prior to cataract surgery can lead to ongoing refractive shifts and blurred vision,” she added. The physicians agreed that, if needed, crosslinking should be performed prior to the cataract surgery. Dr. Venkateswaran recommended monitoring the patient for 3–6 months after crosslinking to ensure keratometric stability. “With the older cataract population, it’s rare to have keratoconus progress, but it’s still important to know if it is progressing,” Dr. Pasricha said. You want to crosslink before cataract surgery, he said, because the crosslinking does have some flattening effect to the cornea. “You want to get the most accurate biometry measurements that will hopefully be relevant for the remainder of that patient’s life,” he said. Dr. Pasricha said that patients usually heal quite well from cataract surgery. “When refitting patients with a history of scleral lenses or rigid gas permeable lenses, you might want to wait longer than a month after surgery to do the final fitting.” he said. In his own experience, Dr. Pasricha usually waits at least 3 months. Jeff Pettey, MD, Cataract Editorial Board member, shared how he has knocked down clinical and surgical challenges: One challenge I’ve overcome is my past techniques of compounding weak zonules by rotating the lens in the bag. I’ve adopted two techniques to allow rotation-less cataract surgery in the setting of loose zonules, which has improved patient outcomes. CATARACT “I advise that if patients are hard contact lens dependent, they should expect to obtain the highest image quality with hard lenses after cataract surgery.” Nandini Venkateswaran, MD
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