30 EyeWorld Asia-Pacific | June 2025 Opacified corneas can present an additional challenge when preparing a patient for cataract surgery. Several physicians discussed how they handle these patients and specific considerations. “The challenge with a patient who has both a corneal opacity and a cataract is determining the relative contribution of each to the visual impairment,” said Kevin M. Miller, MD. Sometimes you don’t know, he said, adding that the sequence—or whether to address both issues simultaneously— is important, especially 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 stationary 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 without intervention on the cornea, 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 sometimes it’s necessary to address the cornea first. The benefit of addressing the cornea first is that it stabilizes the ocular environment and may yield a better refractive result following cataract surgery, especially 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 cornea 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, and if they’re still having problems, handle the cornea issue. The LAL works well following a successful corneal transplant, he said. However, if a scar is present, the LAL is not advisable, as UV light may not adequately penetrate the opacity. 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 condition is Fuchs dystrophy, where a DMEK and cataract surgery combined is a common plan, he said. If the patient has a dense scar that limits visualization, and only a mildto-moderate cataract, he performs a corneal transplant first and delays cataract surgery until the corneal curvature stabilizes. CORNEA by Ellen Stodola, Editorial Co-Director Handling Opacified Corneas When Cataract Surgery Is Needed
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