32 EyeWorld Asia-Pacific | June 2025 CORNEA capsule while performing a capsulorhexis. A light pipe can effectively improve intraocular visibility during surgery without a clear cornea.” Dr. Miller also highlighted some considerations during surgery in these cases. If the corneal problem is progressive, like endothelial failure, the cataract operation is going to make that problem even worse, he said. “We do everything we can to reduce trauma to the endothelium,” he said. “That means using plenty of dispersive viscoelastic, replacing it as often as you need to.” If the issue is a stromal scar and the endothelium is healthy, standard cataract surgery may be sufficient, but you might have to move the eye around during surgery so you’re viewing through a part of the cornea that’s clear. Often, it can help to use dyes like trypan blue to enhance contrast. Dr. Miller said it’s not ideal to use multifocals, EDOF lenses, or toric lenses if the cornea is irregular. If there’s any chance a patient is going to need a rigid contact lens to even out the cornea irregularity, the last thing you want to do is implant a toric lens, he said. “A general rule of thumb with poor corneas is to select a simple monofocal IOL, Dr. Miller said, with the exception of the LAL being an option as long as there’s no corneal opacity. Dr. Hardten likes to use trypan blue for capsular staining when the view is marginal, and he said this helps avoid the anterior capsular rim with the phaco tip and aids in lens placement in the capsular bag. Newer microscopes help with better red reflex and visualization. “I typically use my usual monofocal IOL for these cases,” he said, agreeing with Dr. Miller that you should avoid toric or multifocal when there is significant corneal opacity or irregular astigmatism.Many patients benefit from scleral lenses several weeks postoperatively. If the patient still has inadequate vision, another discussion on corneal transplant or PTK could be had, he said. For postoperative considerations, Dr. Miller said this gets back to the initial discussion of whether the problem in the cornea is stationary or progressive. If it’s stationary, you do routine postoperative care, and if vision is reasonably good, have the patient come back in a year. With a progressive condition and cornea/endothelial failure, you must keep watching the patient. If they progress to endothelial failure, you’ll have to manage it. If they don’t fail, they may have to wear glasses for watching TV or driving if you targeted mild myopia, but if they do, they’ll have been set up nicely for a corneal transplant. He added that for patients in whom a corneal transplant is likely, he’ll overpower the lens to leave the patient a little myopic because an endothelial keratoplasty will push them in a hyperopic direction. Dr. Syed said that if there is significant corneal scarring that extends to the peripheral cornea, the stroma often loses its sponginess, and incisions may not self-seal as they would normally. “I typically have 10-0 nylon sutures on standby in case sutures are needed to seal the incisions. If the opacity is due to a herpetic etiology, viral reactivation is a possibility, and the patient should be monitored closely for any flare-ups while on antiviral prophylaxis,” she said. “Given that the intraoperative view was likely inadequate, there may also be small, retained lens fragments present postoperatively that were not removed entirely during surgery and may cause prolonged inflammation.” Dr. Syed finds that preoperative counseling is key. In patients undergoing cataract surgery with an opacified cornea, the surgeon should explain beforehand that the cornea and not just the cataract is playing a role in their visual symptoms. While some visual improvement is expected, the final vision will be limited to some degree by the opacified cornea. Dealing with corneal opacities is common in a typical practice, Dr. Miller said. A lot of patients get corneal ulcers or trauma to the eye, and you see these patients many times a year. Most people have developed their own little tricks to manage them, he added. About the Physicians David R. Hardten, MD | Attending Surgeon, Minnesota Eye Consultants, Minnetonka, Minnesota | drhardten@mneye.com Kevin M. Miller, MD | Kolokotrones Chair in Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California | kmiller@ucla.edu Zeba A. Syed, MD | Director of the Cornea Fellowship Program, Associate Professor of Ophthalmology, Wills Eye Hospital, Philadelphia, Pennsylvania | zsyed@willseye.org Relevant Disclosures Hardten: None Miller: None Syed: None This article originally appeared in the March 2025 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp.
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