Cataract Surgery in Patients with Corneal Opacities

When the view through the cornea is poor, adjustments in illumination, capsular staining, and pupil expansion can help.

Boris Malyugin, MD, PhD

Cataract and Refractive Surgery Today

KEY TAKEAWAYS Corneal opacities can compromise visualization during cataract surgery, but microscope illumination adjustments and supplemental light can improve the surgical view Transcorneal, intracameral, or pars plana chandelier illumination can enhance lens visualization by using reflected retinal light when coaxial light is insufficient Capsular staining, posterior capsule–safe phaco technique, and pupil expansion with a Malyugin Ring 2.0 or iris hooks can further improve control In eyes with corneal opacities, visualization of the capsule and lens can be challenging. The degree of difficulty depends on the density and location of the opacity. When cataract surgery alone, rather than a combined corneal and cataract procedure, is planned, several techniques can improve visualization. OPTIMIZING VISUALIZATION The first technique to improve visualization is to adjust the intensity of the operating microscope light and the balance between the coaxial and paraxial illumination. The second is to add supplemental illumination. A light pipe borrowed from a vitreoretinal setup can be positioned on the cornea near the limbus for transcorneal illumination or introduced into the anterior chamber through a paracentesis incision for intracameral illumination. Pars plana chandelier illumination can be useful in these cases. This technique was first described by Oshima et al in 2007.1 The approach is illustrated in Figures 1 and 2. When the coaxial microscope light is turned off and the chandelier illuminator is turned on, light reflects off the retina and improves visualization of the lens structures.

The Life-Altering Burden of Keratoconus

Early intervention and thoughtful surgical planning can restore functional vision, increase independence, and improve quality of life in patients with keratoconus.

Brooke Messer, OD, FAAO, FSLS

Cataract and Refractive Surgery Today

Key Takeaways Keratoconus management requires an interventional mindset that treats at diagnosis rather than waiting for visual acuity to decline. Early CXL can reduce substantial lifetime out-of-pocket costs and lessen the quality-of-life burden associated with progressive disease. Suspect keratoconus in young patients whose vision cannot be corrected to a crisp 20/20, who report difficulty with nighttime driving, or who show rapid changes in myopia or astigmatism. Inconsistency between autorefraction and manifest refraction is another clue. Corneal tissue addition keratoplasty can serve as a useful midpoint in select patients with keratoconus between contact lens failure and corneal transplantation. Customized donor tissue regularizes the corneal surface, helping normalize corneal shape and reduce irregular astigmatism. Keratoconus is the most common type of primary corneal ectasia. It has a multifactorial etiology, with genetic and environmental factors contributing to weakening of the corneal collagen fibers and the development of a cone-shaped cornea. Keratoconus is associated with a wide range of systemic conditions, including atopy, connective tissue disorders, obstructive sleep apnea, and Down syndrome.1 Eye care providers are well acquainted with the visual consequences of keratoconus, but we typically see these patients only once or twice a year, which makes it easy for us to underestimate the profound effect the disease can have on their lives. THE QUALITY-OF-LIFE BURDEN OF KERATOCONUS A recent study identified seven quality-of-life (QOL) domains affected by keratoconus, including driving, finances, career, and personal relationships (Table).2 The study authors noted that patients with keratoconus often felt guilt or shame about relying on others, which could contribute to those patients’ withdrawal from social activities.

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