46 EyeWorld Asia-Pacific | December 2024 When explaining guttae to patients, Dr. Price likens them to raindrops on a windshield. A few scattered guttae don’t noticeably degrade vision, but as you get more, they start to affect vision. Like raindrops, guttae cause light scattering. “If there are significant guttae over the pupillary area, he’ll typically do a combined case with cataract and DMEK,” Dr. Price said. “That said, it’s harder to hit the refractive target with the IOL because the guttae and clinically evident or sub-clinical edema associated with Fuchs dystrophy throw off the accuracy of biometry. Even when preoperative corneal edema is not discernible by slit lamp exam, we notice that the central corneal thickness usually decreases after DMEK in eyes with Fuchs dystrophy, and those changes affect the refractive accuracy,” he said. Dr. Price recommends three options to patients with cataracts and Fuchs: 1. Do a combined case with a standard monofocal lens. Most patients do well, but the final postoperative spherical equivalent can range –2 to +3 D from the target, and that’s a big range because with standard cataract surgery, most fall within ±0.5 D of the target. A high degree of refractive accuracy is required for satisfactory use of a multifocal IOL, so these are contraindicated in combined procedures.7 2. For patients who want a multifocal lens and have cataract and Fuchs, Dr. Price will do DMEK first and put the multifocal lens in 2–3 months later. With this staged approach, you need to do the cataract second because the patient will still have irregularity from Fuchs that throws off the biometry to select IOL power, if cataract surgery is performed first.8 About the Physicians Francis Price Jr., MD | Price Vision Group, Indianapolis, Indiana | fprice@pricevisiongroup.net Zeba A. Syed, MD | Director, Cornea Fellowship Program, Wills Eye Hospital, Philadelphia, Pennsylvania | zsyed@willseye.org Relevant Disclosures Price: RxSight Syed: None References 1. Das AV, Chaurasia S. Clinical profile and demographic distribution of Fuchs’ endothelial dystrophy: An electronic medical record-driven big data analytics from an eye care network in India. Indian J Ophthalmol. 2022;70:2415–2420. 2. Vallabh NA, et al. Corneal endothelial cell loss in glaucoma and glaucoma surgery and the utility of management with Descemet membrane endothelial keratoplasty (DMEK). J Ophthalmol. 2022;2022:1315299. 3. Alfawaz AM, et al. Corneal endothelium in patients with anterior uveitis. Ophthalmology. 2016;123:1637–1645. 4. Kaup S, Pandey SK. Cataract surgery in patients with Fuchs’ endothelial corneal dystrophy. Community Eye Health. 2019;31:86–87. 5. Sharma N, et al. Corneal edema after phacoemulsification. Indian J Ophthalmol. 2017;65:1381–1389. 6. Antonini M, et al. Rho-associated kinase inhibitor eye drops in challenging cataract surgery. Am J Ophthalmol Case Rep. 2021;25:101245. 7. Schoenberg ED, et al. Refractive outcomes of Descemet membrane endothelial keratoplasty triple procedures (combined with cataract surgery). J Cataract Refract Surg. 2015;41:1182–1189. 8. Price MO, et al. Implantation of presbyopia-correcting intraocular lenses staged after Descemet membrane endothelial keratoplasty in patients with Fuchs dystrophy. Cornea. 2020;39:732–735. 9. Price DA, et al. Initial results of DMEK combined with cataract surgery and implantation of the light-adjustable lens. J Cataract Refract Surg. 2024;50:270–275. 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. 3. The last option he mentioned was DMEK combined with implantation of a Light Adjustable Lens (LAL, RxSight). The LAL is approved for 2 D of postoperative adjustment, so that almost covers the range of error, Dr. Price said. It gives you a good chance of getting most patients close to plano. He uses the LAL for a quarter of patients in whom he does combined cases and has published on this approach.9 It takes longer for refractions to stabilize after DMEK than after standard cataract surgery, so he is slower to proceed with lens adjustment and lock-in after combined procedures. In cases of visually significant cataract with moderate to severe Fuchs or with significant corneal edema, Dr. Syed said she often combines cataract surgery with an endothelial keratoplasty. “The benefit of this approach is that it saves the patient from requiring a second surgery.” Intraoperatively, these cases may be challenging due to reduced visualization through an edematous cornea. “I find epithelial debridement improves the view significantly in cases of epithelial edema,” Dr. Syed said. “Keratometry changes after endothelial keratoplasty can be highly unpredictable, particularly in those with superficial edema. Hence, I counsel these patients on the likely need for spectacle correction after combined endothelial keratoplasty and cataract surgery.” Dr. Syed will also use staged endothelial keratoplasty followed by cataract surgery, particularly when patients have higher refractive expectations or needs. “This approach is helpful in individuals who desire a toric or presbyopia- correcting IOL,” she said. “Of course, the risk in this case is further endothelial cell loss in the graft secondary to cataract surgery.” CORNEA
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