REVIEW

CURRENT
OPINION Cataract surgery in corneal transplantation
Caterina Sarnicola a,b, Enrica Sarnicola a,b, Edoardo Panico c, Claudio Panico a,
and Vincenzo Sarnicola b

Purpose of review
Corneal diseases are often associated with lens opacity. The present article reviews the recent advances in
the management of cataract and corneal transplant.
Recent findings
Thanks to the development of lamellar transplant techniques and the evolution of cataract surgery, we now
have several strategies to address corneal diseases and cataract including ‘lamellar triple procedure’.
Numerous precautions have been identified to have a successful surgery with good visual recovery.
Summary
Corneal diseases associated with cataract can be successfully managed using separate or combined
surgical procedures, as appropriate. In most cases the intraocular lens power can be calculated with a
predictable outcome.
Keywords
cataract surgery, deep anterior lamellar keratoplasty, Descemet membrane endothelial keratoplasty,
descemet stripping endothelial keratoplasty, keratoplasty, triple procedure

INTRODUCTION DEEP ANTERIOR LAMELLAR

Corneal disorders requiring keratoplasty may be
associated with the presence of cataract.
In the past, combined surgery of penetrating
keratoplasty (PKP) with extracapsular cataract sur-
gery and intraocular lens (IOL) implantation, the so-
called triple procedure, has been widely used in such
patients. The advantages that have led to the predi-
lection of the PKP triple procedure, compared with
sequential procedure, are rapid visual rehabilitation
and no additional endothelial trauma. However,
this approach is burdened by open sky surgery com-
plications such as uncontrollable vitreous pressure,
which can cause posterior capsule rupture and diffi-
culty of IOL implantation, and of the baleful expul-
sive hemorrhage [1].
Following advances in phacoemulsification
technology and viscoelastics, cataract surgery per-
formed after PKP has been reported to be safe and
effective in terms of producing less endothelial
damage and improving visual function compared
with the triple procedure [2,3].
More recently, the development of lamellar ker-
atoplasty radically changed the surgical strategy for
corneal diseases. Targeted lamellar replacement of
corneal tissue has become the procedure of choice
thanks to lower risk of rejection, greater graft sur-
vival, and better visual outcome. Therefore, PKP
finds increasingly less indications [4].
KERATOPLASTY AND CATARACT
SURGERY
Deep anterior lamellar keratoplasty (DALK) is the
gold standard for corneal stroma diseases with
healthy endothelium [5].
Although it is a technically complex interven-
tion, the procedure has become increasingly wide-
spread thanks to the introduction of the Big-bubble
technique described by Anwar and Teichmann [6]
and the increase in efficacy and safety with the use
of a special dedicated cannula [5,7–9].
As DALK has become more diffused, cases
requiring cataract surgery after DALK have
increased.
Acar et al. [10] compared endothelial cell density
(ECD) after cataract surgery in eyes with previous
PKP, DALK or no previous surgery. They found that
PKP group had significantly greater endothelial cell
loss (ECL) than eyes with previous DALK or no
previous surgery.
a
Ophthalmology Department II, Ospedale San Giovanni Bosco and
Ospedale Oftalmico, Turin, bClinica degli Occhi Sarnicola, Grosseto
and cUniversità degli studi di Torino, Turin, Italy
Correspondence to Caterina Sarnicola, MD, Via Juvarra, 19, 10122 Turin,
Italy. Tel: +39 0115661566; e-mail: c.sarnicola@hotmail.it
Curr Opin Ophthalmol 2020, 31:23–27
DOI:10.1097/ICU.0000000000000635

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Cataract surgery and lens implantation
KEY POINTS
 Preoperative assessment of the entity of the corneal
involvement and lens opacity is crucial to choose the
best procedure and surgical timing.
 In a previous keratoplasty, toric IOLs can be used once
refractive stability is achieved, after suture removal.
 Endothelial keratoplasty triple procedure and staged
surgery are effective to manage significant cataract and
endothelial dysfunction and allows a good
predictability of postoperative refraction.
Recently, Den et al. conducted an age-matched
and disease-matched case–control study including
60 eyes that underwent phacoemulsification with
IOL insertion after PKP or DALK. They found that
the ECD in eyes that had previous DALK stabilized
by 1 month after cataract surgery. In contrast, a
continuous decrease in ECD was noted in eyes that
had previous PKP, and the differences in ECD
between these two groups became evident at
&&
6 months [11 ].
Addressing cataract surgery with a stable refrac-
tion, after graft sutures removal, allows an optimal
choice of IOL power and it may help in reducing the
amount of residual ametropia. Moreover, toric IOLs,
and relaxing incisions can be adopted to manage
postkeratoplasty astigmatism [12,13] so that staged
procedures (DALK first and subsequently cataract
surgery) allow a more predictable and satisfying
visual outcome.
Some authors have suggested the use a modified
triple procedure, performing a simultaneous DALK,
phacoemulsification and IOL implantation to man-
age patients with concomitant corneal disease and
cataract [14–16]. Patients with variable grade of
cataract were included in these studies.
It is our opinion that a staged procedure is
preferable than a DALK triple procedure allowing
a better choice of IOL, unless in cases of very
advanced cataract.
ENDOTHELIAL KERATOPLASTY AND
CATARACT SURGERY
Endothelial keratoplasty has evolved rapidly over
the past 20 years and now it is the procedure of
choice for the treatment of endothelial dysfunction.
It allows for faster and superior visual outcome and
less risk of rejection, intraoperative disasters during
‘open-sky’ time, suture-related problems, and weak-
ening of tectonic strength of the eye compared with
PKP [17,18].
24 www.co-ophthalmology.com
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Candidates for endothelial keratoplasty include
patients with any type of endothelial dysfunction.
The concomitant management of both cataract and
endothelial dysfunction is often required, being
Fuchs endothelial corneal dystrophy (FECD) the
leading indication for keratoplasty, and affecting
typically elderly patients [19,20].
As outcomes of endothelial keratoplasty got
better over time, the improved risk-to-benefit ratio
for patients has changed timing and indications for
endothelial keratoplasty. When PKP was the only
surgical option, transplantation was often post-
poned as long as possible, typically until the disease
was very advanced, and so was the cataract manage-
ment, to delay the risk of possible post phacoemul-
sification corneal decompensation. The advantages
of selective endothelial replacement techniques
allow endothelial diseases to be treated at an
earlier stage before their visual disabilities become
severe [19].
Descemet stripping endothelial keratoplasty
(DSEK) is the most widely used endothelial kerato-
plasty technique, but surgeons are increasingly mov-
ing toward thinner-cut DSEK or Descemet membrane
endothelial keratoplasty (DMEK), because reducing
or eliminating donor stroma provides superior visual
outcomes, faster visual rehabilitation, less refractive
error, while reducing the risk of immunologic rejec-
tion. This is best attained with DMEK, which provides
an exact anatomic replacement of dysfunctional host
&
endothelium [21,22 ]. The rate of ECL, primary and
secondary graft failure, and other intraoperative and
postoperative complications during and after DMEK
have been shown to be comparable with those during
and after DSEK. However, DMEK is more technically
challenging and could involve a higher rate of rebub-
bling and graft failure than in DSEK during the early
part of the learning curve or in complex cases (prior
vitrectomy, prior glaucoma shunt surgery, aniridic
&&
eyes and aphakic eyes) [23 ,24].
Staged versus triple endothelial keratoplasty
procedure
Surgical planning must take in consideration the
entity of both corneal dysfunction and lens opacity.
In cases of significant cataract and mild, non-
confluent guttae, with a relatively clear cornea,
cataract surgery can be performed alone using tech-
niques to protect the corneal endothelium. In cases
were cataract surgery provide a significant improve-
ment of visual acuity, corneal transplant can be
delay or not necessary.
In cases with corneal endothelial dysfunction
and little or no lens opacity, the dilemma is whether
to leave the eye phakic or perform both endothelial
Volume 31  Number 1  January 2020

keratoplasty and cataract surgery. Few aspects have to
be taken in consideration when making this choice.
As other ocular surgeries, endothelial keratoplasty
increases the risk of cataract progression [25–27].
The risk of postendothelial keratoplasty cataract for-
mation is probably related to the surgical trauma and
the steroids antirejection regimen. Nevertheless, age
has also been showed to be a significant risk factor
too; the probability of cataract extraction after DSEK
within 3 years was 55% in patients who were over the
age of 50 at the time of transplant vs. 7% in younger
patients [25,26]. Shallow anterior chamber depth is
also a risk factor for cataract development after endo-
thelial keratoplasty [28].
Given these findings and the possibility to per-
form a successful cataract extraction after DSEK or
DMEK, without additional intraoperative or postop-
erative complications [25–27], it may be preferable
to perform endothelial keratoplasty alone in
patients under 50 years with no visually significant
lens opacity. This approach consents to preserve the
accommodation in these fairly young patients.
Older patients with a clear lens, should be advised
about the pros and cons of each procedure to help
them make an informed choice [21].
Conversely, management of endothelial dys-
function with coexisting cataract requires combined
or staged endothelial keratoplasty and cataract
extraction procedures.
Triple procedure is indicated in patients affected
by significant cataract and it may be preferable
because reduces the overall healthcare costs and
the surgical risk for the patient by eliminating an
extra trip to the operating room [29,30].
Precautions that should be taken for a successful
combined surgery are the use of a highly cohesive
viscoelastic, which can be completely removed from
the anterior chamber before inserting the tissue, and
a smaller capsulorhexis that allows more IOL stabil-
ity during the transplant [29].
In regards of postoperative complications, sev-
eral studies have been shown that there is nonsig-
nificant difference in ECL between staged and
combined endothelial keratoplasty and cataract sur-
gery neither in descemet stripping endothelial ker-
atoplasty (DSAEK) or DMEK procedures [29,30,31].
Furthermore, Pedemonte-Sarrias compared the
incidence of cystoid macular edema (CME) after
DSAEK alone (41 eyes) and combined with cataract
surgery (14 eyes). They found that CME appears more
frequently after triple procedure: 21% after triple
DSAEK procedure vs. 7% after DSAEK alone [32].
Significantly, Hoerster et al. [33] found a reduced
incidence of CME after triple-DMEK surgery inten-
sifying topical steroid therapy during the first
postoperative week.
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Cataract surgery in corneal transplantation Sarnicola et al.
In recent times, Crews et al. found an increased
risk for hyphema performing peripheral iridotomy
when DMEK was combined with cataract surgery. In
their series, intraoperative hyphema did not signifi-
cantly affect the rebubbling rate, ECL, or visual
&
acuity outcomes [34 ].
Although the evidence in the literature shows
that the triple procedure is safe and advantageous in
some aspects, many surgeons still prefer to address
the cataract first and subsequently perform an
endothelial keratoplasty.
Intraocular lens selection and power
calculation
The hyperopic shift caused by the endothelial kera-
toplasty must be taken into consideration for choos-
ing the IOL power. Most authors recommend a
refractive target of 0.8 to 1.25 D for DSAEK and
of 0.50 to 1.0 D for DMEK to provide near emme-
tropia [29,35–37].
However, in advanced FECD cases, IOL power
selection may be more challenging due to possible
changes in the anterior corneal curvature [35].
To date few data are available in the literature
about the use of toric IOLs in patients that need
endothelial keratoplasty. Schoenberg et al. [38]
reported the use of toric IOLs in nine patients that
underwent a triple DMEK procedure and it effec-
tively reduced refractive cylinder for patients with
more than 1.75 D of preoperative regular topo-
graphic astigmatism, while mild or irregular astig-
matism tended to regress toward a mean of
approximately 1.0 D.
More recently, Yokogawa et al. published the
first vector analysis about toric lens implantation
for astigmatism correction during triple DMEK pro-
cedure.
Thirteen eyes were included in the study: 61.5%
of eyes achieved uncorrected distance visual acuity
(UDVA) 20/40 and 53.6% of eyes achieved UDVA
20/25. Rotational misalignment by 43 degrees clock-
wise was noted in one patient with oblique preop-
erative astigmatism. They also found the tendency
toward overcorrection of the online toric calculator
in eyes with preoperative with-the-rule corneal
&
astigmatism [39 ].
Interesting, Zeidenweber et al. reviewed the
visual outcome of DMEK in patients who had under-
gone refractive surgery. They reported favorable
visual acuity results with 90% of eyes that reached
20/25 vision with correction and 75% that reached
20/40 without correction.
They also identified six eyes (30% of cases) with
more than 30 degrees of axis shift. These data speak
strongly about not using toric IOLs in patients with
www.co-ophthalmology.com 25
Cataract surgery and lens implantation
corneal edema from endothelial dysfunction with
&
previous refractive surgery [40 ].
As well as the IOL power also the choice of the
material is very important. Several reports have
described a phenomenon of calcification of hydro-
philic acrylic IOLs (including a hydrophilic acrylic
IOL with a hydrophobic surface), following proce-
dures using intracameral injection of air or gas [41–
43]. Therefore, in patients with endothelial diseases,
who may need a corneal transplant, the use of
hydrophobic IOLs is recommended.
CONCLUSION
Assess the entity of corneal disease and lens opacity
is crucial to choose the best procedure and surgical
timing.
In case of corneal stromal diseases with healthy
endothelium, addressing the cataract after DALK
sutures removal consents an optimal IOL choice.
In case of significant cataract and endothelial
dysfunction, endothelial keratoplasty triple proce-
dure seems to be the best option.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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