30 EyeWorld Asia-Pacific | December 2024 CATARACT About the Physicians Neel Pasricha, MD | Assistant Professor of Ophthalmology, University of California, San Francisco, California | neel.pasricha@ucsf.edu Nandini Venkateswaran, MD | Assistant Professor of Ophthalmology, Harvard Medical School Cornea and Refractive Surgery Service, Massachusetts Eye and Ear, Lexington, Lexington, Massachusetts | nandini.venkat89@gmail.com Relevant Disclosures Pasricha: None Venkateswaran: Glaukos Reference 1. Heath MT, et al. Intraocular lens power calculations in keratoconus eyes comparing keratometry, total keratometry, and newer formulae. Am J Ophthalmol. 2023;253:206–214. This article originally appeared in the September 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. ASIA-PACIFIC PERSPECTIVES Samaresh Srivastava, MD Director, Jaipur A 16 Vijay Path, Tilak Nagar, Jaipur samaresh@raghudeepeyeclinic.com Cataract surgery in patients with keratoconus presents unique challenges that demand a comprehensive, threepronged approach encompassing meticulous preoperative planning, customized surgical techniques, and vigilant postoperative management. The article effectively outlines these critical aspects while providing practical insights for achieving optimal outcomes. Preoperative Considerations While keratoconus stability is generally assured in elderly patients presenting with senile cataracts, the increasing prevalence of early-onset cataracts necessitates careful evaluation for disease progression. The authors appropriately emphasize the importance of corneal stabilization procedures when indicated. The Barrett True-K Formula emerges as the preferred calculator for IOL power determination, though the article rightly cautions about the possibility of biometric surprises despite careful planning. A crucial preoperative step includes discontinuing contact lens wear for a minimum of two weeks before biometry to ensure reliable keratometry readings. Surgical Approach The surgical technique requires several important modifications. The article highlights the significance of incision placement, particularly noting that while standard temporal or superior approaches remain viable, inferior side port placement requires special consideration due to the typically ectatic inferior cornea. The authors recommend scleral incisions and maintain a low threshold for suturing. The deep anterior chamber characteristic of these eyes necessitates adjustments to surgical parameters, specifically advocating for lower intraocular pressure and reduced flow rates during phacoemulsification. IOL Selection and Special Considerations The authors present a nuanced approach to IOL selection based on astigmatism patterns. In cases of regular astigmatism, toric IOLs may be considered, while irregular astigmatism cases are better served with spherical or aspheric options. Mesopic pupil size documentation is emphasized as a critical preoperative parameter. The article appropriately notes that while lamellar corneal surgery may be necessary for extensively scarred corneas, single-stage cataract surgery often suffices in cases with clear corneas. Long-term Management The article concludes by emphasizing the importance of longitudinal follow-up to monitor for disease progression, highlighting that these patients require lifelong surveillance. This perpetual monitoring strategy ensures early detection and management of any post-surgical complications or disease progression. Overall, the article provides a comprehensive framework for managing cataract surgery in keratoconic patients, effectively balancing theoretical principles with practical surgical pearls. The authors’ systematic approach offers valuable guidance for anterior segment surgeons managing this challenging subset of patients. Editors’ note: Dr. Samaresh Srivastava disclosed no relevant financial interests.
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