Cataract Surgery and Comorbidities with the Maestros

It was back to school for Cornea Day in one of the opening sessions of the 40th Congress of the European Society of Cataract and Refractive Surgeons (ESCRS 2022) as top doctors went full throttle on comorbidities and cataract surgery…

If the crowd in Space 3 of the MiCo (Allianz MiCo) – Milano Convention Centre was any indication, the future of ophthalmology burns bright. Your correspondent had to jostle and bump his way through a swelling crowd of young doctors just to find a place to sit. 

The superficial expectation was that this would be just another run-of-the-mill early-conference session at ESCRS 2022 in Milan, Italy. But the reality was something different. What unfolded over the following 90 minutes was nothing less than a masterclass on one of the most complex and wide-ranging topics in anterior segment – what to do with cataract surgeries in the face of comorbidities. 

Getting Down with OSD

It was the good stuff first with perhaps the most common and critical comorbidity to consider before cataract complications come about – ocular surface disease (OSD). Dr. Allan Slomovic of the hallowed University of Toronto flew through a flurry of tips about what to consider with diseases like pterygium, epithelial basement membrane dystrophy, and dry eye disease. 

Pearls abounded for this wide variety of conditions; remove pterygia with conjunctival autograft first, and stay away from NSAIDs in the perioperative period, to name a few among many. But the main takeaway was to manage patient expectations with OSD before they undergo treatment. As Dr. Slomovic reminded the audience, “if you tell them before surgery, they own it; if they become aware after, it’s all your fault.”

Aquarium Amoebas and Other Miscellanea

Imagine – you’re minding your own business, feeding your fish. Suddenly water splashes into your eyes and before you know it, you’ve got amoebas – acanthamoebas, to be exact, and that spells trouble for your cornea. Fortunately, there’s deep anterior lamellar keratoplasty (DALK), and it works wonders for patients with acanthamoeba keratitis (AK).

According to a presentation by Dr. Vincenzo Sarnicola, DALK is quickly replacing more traditional procedures like therapeutic penetrating keratoplasty (TPK) or medicinal interventions.  The key to avoiding failure is to identify surgical patients early, move fast, and not waste time with early or late TPK.  

It was then on to corneal endothelial disease with Dr. Bjöern Bachmann, who presented a variety of evidence for clinicians to take into account when considering options with Descemet’s membrane endothelial keratoplasty (DMEK) and cataract surgery. Combined? Sequential? It all depends, according to Dr. Bachmann. For patients with corneal edema and cataract with a significantly reduced quality of life, combined surgery is the go, but with one important caveat. Presumed postoperative posterior to anterior corneal curvature radii ratio must be taken into account for IOL calculation. 

When things aren’t so critical, the picture gets a bit clearer, however. Demanding patients are strong candidates for a DMEK-first approach, but crucially true posterior to anterior corneal curvature radii ratio is the metric for IOL formulae. And of course, for patients without corneal edema or subclinical corneal edema, it’s best to just go for cataract surgery and avoid DMEK. 

Optics and Formulae, Oh My

The optics and its menagerie of tools and gizmos can be bewildering to ophthalmologists of all ages. But Dr. Damien Gatinel made it his mission to clear the air with optics and the diseased cornea. After all, the cornea provides around 60% of ocular power, and this needs to be taken into account.

One of the main impacts of the diseased cornea is in IOL power calculation, and the distorting effect corneal diseases like keratoconus (KC) can have on getting it right. For Dr. Gatinel, the placido topograph and aberrometer are useful for higher order aberrations (HOAs) and KC, Scheimpflug and swept-source optical coherence tomography (SS-OCT) for corneal HOAs, high resolution optical coherence tomography (HR-OCT) for KC, and double pass aberrometry for scarring, fibrosis, haze, and loss of transparency. 

Dr. Abi Ablafia of Israel continued with keratoconus and its havoc-wreaking influence on intraocular lens (IOL) power calculation. KC drops IOL power calculation prediction accuracy by 80%, but there is some help available despite a relative dearth of research. It is of the highest importance to use a variety of formulae in these calculations, and especially the Kane, Barrett, and SRK/T formulae. But most important of all is patient counseling. And as always, the rule is to underpromise and overdeliver, especially when something as tricky as keratoconus is involved. 

IOL Mania and Fuchs’ Dystrophy

In one of the more entertaining and enlightening presentations of the day, Dr. Ruth Lapid-Gortzak tackled an extended-depth-of-focus (EDOF) IOL implantation after corneal refractive surgery. With her ever-present sharp wit and eye for key points, Dr. Lapid Gortzak lamented the lack of research into this topic both now and in the future, and shared data from her own prestigious practice. 

In the end, she made a call for clinicians to create a database to establish a set of parameters that draw the line between implanting true EDOF IOLs and diffractive premium IOLs. This data would go a long way in helping to solve the currently intractable situation with clinical trials. She also cautioned against asymmetric and refractive IOLs in patients who have undergone refractive surgery, and reinforced a key theme of the session. Patients are more informed than ever before, but doctors still need to be confident in their expertise and the power of saying no.

The final comorbidity discussed was Fuchs’ dystrophy and cataract refractive surgery. With the cornea’s massive influence on optical power, the primary concern was compensating for this in IOL calculations. 

Of course, with solutions like triple DMEK, the usual risks of immune system rejection, progressive cell loss, and graft failure need to be taken into account. Checking and rechecking measurements like K readings and axis measurements are important, but in the end clinicians need to be aware of the degree of severity of the Fuchs’ dystrophy, especially when deciding on premium IOLs. But the crowd favorite takeaway and tip that elicited the praise of moderators? Pay attention to the peripheral cell count. 

Editor’s Note: A version of this article was first published in CAKE POST, ESCRS 2022 Edition, Issue 1. Reporting for this story took place at ESCRS 2022 in Milan, Italy.

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