94

REVIEW/UPDATE

Phacoemulsification with coexisting

corneal opacities
Namrata Sharma, MD, Deepali Singhal, MD, Prafulla Kumar Maharana, MD, Rebika Dhiman, MD,
Himanshu Shekhar, MD, Jeewan S. Titiyal, MD, Tushar Agarwal, MD

The treatment of choice for cases of corneal opacity with signifi-
cant cataract is often a triple procedure. However, in certain situ-
ations the chances of graft survival are poor, for example in cases
with deep vascularization, secondary glaucoma, and healed viral
keratitis. Under these circumstances, performing cataract surgery
only might improve the visual acuity enough to maintain the pa-
tient’s day-to-day activities. Performing cataract surgery, espe-
cially phacoemulsification, in these cases is challenging. Proper
case selection, choosing the right technique, and a thorough
idea about the difficulties and methods of tackling such cases is
paramount to achieving optimum visual outcomes. In this review,
we discuss the case selection and surgical modifications of per-
forming phacoemulsification in cases with coexisting corneal
opacities.
J Cataract Refract Surg 2019; 45:94–100 Q 2018 ASCRS and ESCRS
Online Video

C
orneal opacity is an important cause of blindness,
especially in developing countries such as India;
when associated with cataract, such opacity leads
to further deterioration in vision.1 Phacoemulsification
in eyes with cataract and coexisting corneal opacity in
the presence of corneal haze, in which visualization of
the anterior segment structures is compromised, is chal-
lenging. In this scenario, two approaches can be used.
The first is a 2-stage technique in which keratoplasty is fol-
lowed by phacoemulsification at a later date.2 The second
is simultaneous keratoplasty with cataract extraction and
intraocular lens (IOL) implantation.3
In addition to the conventional triple procedure, which
is penetrating keratoplasty (PKP) with phacoemulsifica-
tion, new techniques such as sutureless anterior lamellar
keratoplasty (SALK), deep anterior lamellar keratoplasty
(DALK), Descemet-stripping automated endothelial ker-
atoplasty (DSAEK), or Descemet membrane endothelial
keratoplasty triple procedures are frequently used by
ophthalmologists worldwide.4 Although in general the
current rates of corneal transplantation surgery success
are high, there is a greater risk for complications and de-
layed visual rehabilitation than with phacoemulsification
alone. Also, the scarcity of donor corneas and the risk for
graft failure, in particular in eyes with high-risk kerato-
plasties, create the need for alternative methods of
improving vision in cases of cataract with corneal
opacification.5
In this review, we discuss the options for managing cata-
ract with coexisting corneal opacities with an emphasis on
phacoemulsification.
GOALS OF SURGERY
The goal of phacoemulsification in cases with coexisting
corneal opacities and a visually debilitating cataract is to
provide optimal visual acuity after phacoemulsification
alone. This technique is preferred mainly in cases in which
the opacity is less extensive or keratoplasty is not feasible
because of the high risk for graft failure.
SELECTION OF CASES
The decision to perform a single-stage surgery versus a
sequential surgery depends on several factors, such as the
location of the opacity, density of the opacity, monocular
or binocular status of patient, surgeon’s expertise, availabil-
ity of donor corneas, and the patient’s expectation in terms
of visual rehabilitation. The major deciding factor for
whether to perform single-stage or sequential surgery is
the location and size of the corneal opacity. In cases with
a peripheral or paracentral opacity with at least one half
of clear cornea so as to allow sufficient visibility during
each step, phacoemulsification alone can suffice. In patients
with a central leucomatous corneal opacity, a combined
procedure might be preferred. This may be especially true
in elderly monocular patients with poor dexterity and those

Submitted: March 27, 2018 | Final revision submitted: July 24, 2018 | Accepted: September 19, 2018
From the Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India.
Corresponding author: Namrata Sharma, MD, Cataract, Cornea & Refractive Surgery Services, Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of
Medical Sciences, New Delhi, 110029, India. Email: namrata103@hotmail.com.

Q 2018 ASCRS and ESCRS 0886-3350/$ - see frontmatter

Published by Elsevier Inc. https://doi.org/10.1016/j.jcrs.2018.09.015
 REVIEW/UPDATE: PHACOEMULSIFICATION WITH COEXISTING CORNEAL OPACITIES
who are less likely to comply with meticulous follow-up af-
ter keratoplasty.6
INDICATIONS FOR SURGERY
The decision to operate in these cases depends on the pre-
vious corrected distance visual acuity (CDVA) and visual
potential. In cases with a small central corneal opacity,
dilated visual acuity and laser interferometry should also
be performed. A history that suggests a recent decrease in
vision, that results in a patient who has a long-standing
corneal opacity becoming nonambulatory, points toward
cataract as the cause of vision loss. Similarly, if the history
suggests that the patient is unable to perform certain visual
activities that he or she was previously capable of, the cata-
ract must be removed.
CONTRAINDICATIONS TO SURGERY
The main contraindication to surgery is poor visual poten-
tial as identified by refraction, laser interferometry, or elec-
trophysiological tests. The presence of other ocular
pathologies, such as optic atrophy, advanced glaucoma,
an old retinal detachment, or macular scar, might be
considered to be important contraindications. However,
the decision to not operate must be based on an individual
case-to-case analysis, and the surgeon must remember that
even 1 quadrant of clear field is a beacon of hope for these
patients.
TYPES OF CORNEAL OPACITIES
In cases with a central corneal opacity, the decision to
perform only phacoemulsification should be done only if
the extent of the opacity is small enough such that it will
allow visual gain after surgery. Patients with a paracentral
corneal opacity are the best candidates for doing phaco-
emulsification only, since the central visual axis may be
clear enough to achieve good vision (Figure 1). In cases
where the corneal opacity is due to systemic pathology,
the opacities are usually diffuse and hence the decision to
proceed with phacoemulsification alone should be taken
95
if the history is suggestive of a recent onset of vision loss,
indicating that it is primarily due to cataract.
AIDS TO FACILITATE SURGERY
The major problems during phacoemulsification include
calculation of the IOL power or biometry, difficult visualiza-
tion, and postoperative care, including visual rehabilitation.
To overcome the difficulties of performing phacoemulsifica-
tion in the presence of corneal opacities, several aids have
been developed to help the surgeon (Figure 2).
Position of the Patient
The decision to use a superior or temporal incision depends
on the location of the opacity. The best position provides a
maximum clear working field.
Microscope Illumination
A microscope with good optics and the best possible light
intensity should be used. During phacoemulsification in
cases of opacity, coaxial illumination is the best to identify
the continuous curvilinear capsulorhexis (CCC) margins
and posterior capsule status. Thus, good coaxial illumina-
tion is essential to providing the maximum possible visibil-
ity at each step. Increasing the intensity of light might also
increase the amount of scattering through the opacity,
further impeding visibility.7 Thus, before surgery begins,
every effort should be made to achieve the best possible mi-
croscope settings, and these can differ in each case.
Ophthalmic Viscosurgical Devices
Dispersive ophthalmic viscosurgical devices (OVDs) have
an important role in phacoemulsification in eyes with opac-
ities and cataract. They protect the endothelium, which is
already compromised in such cases. In addition, they pro-
vide lubrication to the anterior corneal surface, which
further aids in visibility. Curing CCC creation, a cohesive
OVD should be used because such a maneuver is often diffi-
cult, with a high chance of extension in these cases as a
result of poor visibility. Also, a blob of dispersive OVD
placed on the anterior corneal surface increases the
Figure 1. a and b: Preoperative and postoperative clinical pho-
tographs of an eye with healed keratitis and a central mebulo-
macular corneal scar in which the cataract was managed with
phacoemulsification alone; visual acuity improved from count-
ing fingers to 6/18. c and d: Preoperative and postoperative
clinical photograph of an eye with healed keratitis and
adherent leucoma located inferonasally to the visual axis in
which the cataract was managed with phacoemulsification
alone; visual acuity improved from counting fingers to 6/12.
Volume 45 Issue 1 January 2019
96 REVIEW/UPDATE: PHACOEMULSIFICATION WITH COEXISTING CORNEAL OPACITIES

Figure 2. Aids used for phaco-

emulsification in cases of coexist-
ing cataract and corneal opacity.
a: Use of trypan blue 0.06% dye
for capsulorhexis. b: Use of fiber-
optic endoilluminator to assess
the depth of impellement and
chopping of the nucleus. c: Use
of nylon iris hooks to increase the
amount of clear working area.

magnification, which provides better visualization of each Nylon Hooks

surgical step, in particular CCC creation. This can be Cases with corneal opacity and cataract, especially those
repeated several times during any step of the surgery. with healed keratouveitis, are often associated with an
atonic iris. In addition, there might be preexisting posterior
Ophthalmic Dyes synechiae with a poorly dilating pupil. In these cases, nylon
In eyes with advanced or total white cataract, it is difficult to hooks help expand the working area, making surgery safer
distinguish the anterior capsule from the underlying cortex (Figure 2). Thus, nylon hooks should be available during
because of the absence of the red reflex. This increases the surgery in such cases.
risk for intraoperative complications, such as extended
capsule tears, posterior capsule rupture, vitreous loss, nu-
PHACOEMULSIFICATION IN CORNEAL OPACITY
cleus drop, and IOL displacement. Dyes such as fluorescein
Preoperative Workup
sodium 2.0%,8–10 indocyanine green (ICG),8,11,12 trypan
Intraocular lens power calculation is a major issue in cases
blue,8,12,13 and gentian violet 0.01%14 provide better visual-
of coexisting cataract and opacity. Accurate axial length
ization of the anterior lens capsule in eyes with mature cata-
(AL) measurement is a major challenge. Optical biometry
ract. Dada et al.8 compared the safety and efficacy of trypan
may not always be possible due to the corneal opacity. Ul-
blue 0.1%, gentian violet 0.001%, ICG 0.5%, fluorescein
trasonic measurement may be erroneous as the patient
2.0%, and the patient’s autologous blood for anterior
finds it difficult to focus properly in the presence of a
capsule staining in cases of white cataract. They concluded
corneal opacity. However, providing a tactile stimulation
that trypan blue, ICG, and gentian violet are more effective
(eg, patient’s thumb) can ensure proper ocular alignment.
in staining the capsule. These dyes should be used even in
Corneal irregularity may exaggerate the error in AL mea-
routine cases of cataract with coexisting corneal opacity.
surement due to indentation effect. This can be avoided
Trypan blue 0.01% is considered safe when applied to the
by using immersion ultrasonography.
corneal endothelium, and its intraoperative use enhances
The second major problem is measurement of corneal po-
the visibility of the anterior capsule and delineation of the
wer, which is often erroneous. Although there has been much
lenticular morphology during phacoemulsification in eyes
research into identifying an ideal method to calculate corneal
with corneal opacity (Figure 2).15 However, at least a part
power after a refractive procedure, little research has been
of the cornea must be clear to allow visualization of the
performed on calculations for eyes with corneal opacity.
stained capsule and nucleus after capsulorhexis creation.
Manual keratometry or autokeratometry is often not possible
because of irregular mires. Optical biometry is often not
Endoilluminators
possible in such cases and videokeratography appears to be
The anterior chamber illumination technique using a light
the best method to measure corneal power; we have found
pipe has been reported to be helpful during phacoemulsifi-
Scheimpflug-based imaging to be the most useful in these
cation in cases with mild to moderate corneal haze.7,16
cases. However, a slit-scanning system or a Placido disk–
Transscleral or intravitreal or intracameral illumination
based device also can measure the accurate corneal curvature.
are the various techniques described.16–20 Fiber-optic illu-
The alteration in posterior corneal curvature as a conse-
mination is useful for better visualization of the CCC
quence of a full-thickness corneal scar cannot be ignored.
margin, assessment of depth of impalement of the nucleus,
However, to our knowledge, no study has evaluated the
and the site of chopping (Figure 2) as well as to identify the
most accurate technique to measure corneal curvature under
CCC margin during IOL implantation. Twenty-three
such circumstances. True net power and total corneal refrac-
gauge, 25-gauge, and 27-gauge endoilluminators have
tive power measurement can provide fairly accurate mea-
been used in presence of media haze.21–27
surements; however, future studies should explore this topic.
Oshima et al.20 described the use of 25-gauge transcon-
junctival chandelier endoillumination in combination
with a torsional oscillation system for phacoemulsification SURGICAL TECHNIQUE
in patients with severe bullous keratopathy. The major Site of Incision in Relation to the Opacity
advantage of the chandelier system is its self-retaining na- The location of the main incision depends on the quadrant
ture, which leaves the surgeon’s hands free for bimanual of available clear cornea. For example, if the nasal half of the
procedures during cataract surgery. cornea is clear, the incision should be made temporally and

Volume 45 Issue 1 January 2019

 REVIEW/UPDATE: PHACOEMULSIFICATION WITH COEXISTING CORNEAL OPACITIES
if the inferior half is clear, a superior incision is preferred
(Figure 3).
Capsulorhexis Modification
An anterior CCC should be created with the aid of dyes to
improve the visibility, as discussed. Retroillumination
should be used while creating the CCC to better visualize
the anterior capsule against the red reflex. The CCC should
be started in the visible and clear area and, with the help of
forceps, should be continued in a single motion in a centrip-
etal direction without leaving the edge underneath the
opacity (Figure 4). When visualization of the leading edge
is hazy, a blob of dispersive OVD can be placed to increase
the magnification for a second, thereby allowing the sur-
geon to identify the lost edge. Another important modifica-
tion to increase visibility underneath the opacity is manual
rotation or maneuvering of the globe. This step can also be
used to identify the lost edge of the capsulorhexis.
Nuclear Emulsification Modification
Nuclear emulsification with a primary chop technique is
preferred in eyes with corneal opacification and cataract
of grade 2 or higher, whereas in cases of advanced cataract,
an eccentric crater followed by chopping can be used
(Figure 4). However, the surgeon should follow the tech-
nique with which he or she is most comfortable. Phaco-
emulsification should be performed in situ; that is, each
fragment should be emulsified immediately after division
to increase the amount of red glow for further chopping.
This also helps nullify the camouflage effect produced by
the gray nuclear fragments of the corneal opacity. Chop-
ping should be performed under retroillumination only.
In addition, care must be taken to complete phacoemulsifi-
cation in the visible pupillary area by rotating the nucleus
pieces to the largest clear area.
Irrigation/Aspiration Modification
Automated irrigation/aspiration of cortical material should
be performed under retroillumination at the visible area
aided by trypan blue staining of the posterior capsule to
complete cortex aspiration. It is best to use a bimanual
probe.
Figure 3. Varying incision sites according to the field of maximum
visible clear area.
97
Choice and Technique of Intraocular Lens Implantation
A foldable 1- or 3-piece acrylic IOL or rigid poly(methyl
methacrylate) IOL can be implanted in the bag, with the
choice based on the patient’s economic constraints. Retro-
illumination with or without endoillumination should be
used for better visualization of the bag and CCC edge dur-
ing IOL implantation (Figure 4). In eyes with a paracentral
opacity, it is better to avoid an IOL with a small optic
(!5.0 mm). In eyes with suspected posterior capsule
rupture, OVD or triamcinolone acetonide should ne
injected into the anterior chamber to help identify the vit-
reous. In these cases, a 3-piece IOL with routine manage-
ment of posterior capsule rupture is recommended.
Video 1 (available at: http://jcrsjournal.org) shows some
steps of surgery in cases with coexisting cataract and
corneal opacity.
POSTOPERATIVE PROBLEMS
Surgery is only one intervention in a series of steps needed to
restore vision in a patient with concurrent corneal opacity and
cataract. Postoperative care and follow-up are important, at
least as important as the surgery itself, and are the most ne-
glected aspects, especially in rural settings. Postoperative com-
plications, such as raised intraocular pressure, anterior
chamber reaction, graft rejection, and posterior capsule opaci-
fication, must be promptly managed.28 Therefore, it is essen-
tial to assess these postoperative complications and patient
compliance with medications to optimize visual outcomes.
Phacoemulsification with Optical Iridectomy
Optical iridectomy or sphincterotomy is a surgical alterna-
tive to PKP that can be combined, especially in high-risk pe-
diatric patients, bilaterally blind patients, or for eyes with
severe deep corneal stromal vascularization.29–33 In eyes
with cataract and coexisting corneal opacification, phaco-
emulsification with pupil enlargement helps create an opti-
cal window that aids in the addition of peripheral bundle
of rays so that a relatively clear image is produced by the pe-
ripheral rays superimposed on the blurred image of the cen-
tral rays. Miller et al.29 suggest that an area of clear
peripheral cornea can produce retinal images compatible
with 20/30 visual acuity. Hence, they recommend optical iri-
dectomy in appropriate cases of corneal blindness with
patches of clear peripheral cornea. Iridectomy can be per-
formed using simple iridectomy scissors or an automated vi-
trector. Agarwal et al.32 described optical iridectomy using
an automated vitrector through a 1.2 mm incision in 15
eyes with leucomatous corneal opacity; the median CDVA
improved from 1/60 preoperatively to 6/24. The visual
gain, although not on par with that after keratoplasty, is suf-
ficient to enable a visually impaired patient with corneal
opacity to perform day-to-day activities without the risk of
graft-related complications, such as rejection or failure.34
Simultaneous Phacoemulsification and Anterior Lamellar
Keratoplasty
Anterior lamellar keratoplasty procedures such as SALK
and DALK combined with phacoemulsification are useful
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98 REVIEW/UPDATE: PHACOEMULSIFICATION WITH COEXISTING CORNEAL OPACITIES

Figure 4. Step-wise modifications in phacoemulsification in

cases of coexisting cataract and corneal opacity. a: Capsulo-
rhexis performed eccentrically in the visible area with the aid of
trypan blue dye. b and c: Endoillumination used for visualizing
the depth of impellement of the phaco probe into the nucleus
during chopping. d: Coaxial and endoillumination used for
visualizing the edge of capsulorhexis margin during IOL im-
plantation (IOL Z intraocular lens).

Table 1. Outcomes of cataract surgery in the presence of corneal opacity.

Postop
Study* (Year) Diagnosis Eyes (n) Preop CDVA Intervention CDVA/FU Complications (n)
Sridhar28 (2000) CO, cataract 104 Triple procedure R20/40 in Vitreous upthrust (7), PCR (3)
(PKP, ECCE, PC 40% at
IOL) 23 mo
Covert41 (2007) Fuchs dystrophy, cataract 21 20/68 New triple procedure 20/34 at Graft dislocation (3), acute
(DSAEK, Phaco) 6 mo graft rejection (3), pupillary
block glaucoma (2)
Terry40 (2009) Fuchs dystrophy, cataract 225 20/52 New triple procedure R20/40 in Graft dislocation (4)
(DSAEK, Phaco) 97% at
12 mo
Padmanabhan42 Endothelial dysfunction, 54 1.07 G 0.63 New triple procedure 0.26 G 0.15 Higher endothelial cell loss
(2010) cataract logMAR logMAR at
3 mo
Padmanabhan42 Corneal scars, cataract 26 1.74 G 0.41 Conventional triple 0.87 G 0.46 PED, suture-related problem
(2010) logMAR (PKP, ECCE, IOL) logMAR at
3 mo
Panda35 (2011) Deep central CO, cataract 22 HM DALK, phaco R20/60 in PCR (2)
81% at
3 mo
Panda33 (2012) Central CO, cataract 205 !40/200 Phaco, other R20/60 at Aphakia (1)
maneuvers 3 mo
(sphincterotomy,
synechiolysis)
Chaurasia44 (2014) Fuchs dystrophy, secondary 200 20/40 DMEK triple 20/20 at Primary graft failure (7), CME
corneal edema, failed 6 mo (3)
endothelial keratoplasty
Zaki37 (2015) CO, cataract 3 2/60 DALK triple (DALK, R6/12 at None
phaco, PC IOL) 18 mo
Agarwal38 (2015) Anterior CO, cataract 6 1.3 G 0.1 SALK, phaco 0.4 G 0.2 Graft rejection
logMAR logMAR at
6 mo
Yokogawa47 Fuchs dystrophy Krachmer 15 0.21 G 0.15 DMEK triple (DMEK, 0.08 G 0.12 None
(2017) grades 4 & 5 logMAR phaco, toric IOL) logMAR at
10 mo

CDVA Z corrected distance visual acuity; CME Z cystoid macular edema; CO Z corneal opacity; DMEK Z Descemet membrane endothelial keratoplasty;
DSAEK Z Descemet-stripping automated endothelial keratoplasty; ECCE Z extracapsular cataract extraction; FU Z follow-up; HM Z hand motions;
IOL Z intraocular lens; logMAR Z logarithm of the minimum angle of resolution; PC Z posterior chamber; PCR Z posterior capsule rupture;
PED Z persistent epithelial defect; PKP Z penetrating keratoplasty; SALK Z sutureless anterior lamellar keratoplasty
*First author

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 REVIEW/UPDATE: PHACOEMULSIFICATION WITH COEXISTING CORNEAL OPACITIES
for corneal opacities not involving the endothelium. The
basic principle involves initial host debulking to improve
visibility followed by phacoemulsification. Next, the graft
is sutured or is put in place with fibrin glue.4 Panda
et al.35 found encouraging results with simultaneous
DALK and phacoemulsification, with a significant
improvement in CDVA to better than 20/60 in all cases.
The DALK triple procedure has also been performed suc-
cessfully in eyes with a bare pre-Descemet layer, which is
tougher and more resilient than Descemet membrane and
can withstand pressure during phacoemulsification.36,37
Microkeratome-assisted SALK has also been combined
with phacoemulsification, with good visual outcomes.38
Simultaneous Phacoemulsification and Endothelial
Keratoplasty
Phacoemulsification can be combined with endothelial
keratoplasty in presence of corneal edema and coexisting
cataract. Often, these cases are associated with subepithelial
haze that can be cleared using simple debridement.
Subsequent phacoemulsification followed by endothelial
keratoplasty can be performed after any standard
technique. Price and Price39 and Terry et al.40 reported
excellent visual outcomes after the DSAEK triple
procedure, with a CDVA of 20/40 or better in 97% of cases
and a low risk for graft dislocation (1.8%). The refractive
spherical equivalent at the 1-year follow-up was within
G1.0 diopter (D) of emmetropia in 73% of cases and within
G2.0 D in 95% of cases.40 Similar visual outcomes have
been reported in other series of endothelial keratoplasty
99
Figure 5. Algorithm for management of cases
with cataract and coexisting corneal opacity
(ALTK Z automated lamellar therapeutic ker-
atoplasty; DALK Z deep anterior lamellar
keratoplasty; DMEK Z Descemet membrane
endothelial keratoplasty; DSAEK Z Desce-
met-stripping automated endothelial kerato-
plasty; DSEK Z Descemet-stripping
endothelial keratoplasty; PTK Z photothera-
peutic keratectomy; SALK Z sutureless
anterior lamellar keratoplasty).
with phacoemulsification,39–47 with excellent postoperative
refractive predictability (Table 1).28,33,35,37,38,40–42,44,47
The key modification during phacoemulsification with
endothelial keratoplasty is that initially, trypan blue–
assisted host Descemet membrane removal is performed
to improve visibility; this is followed by phacoemulsifica-
tion. Next, the graft is inserted, which helps to prevent
endothelial loss in the graft. Other modifications in phaco-
emulsification are the same as those described above.
ALGORITHM TO MANAGE PREEXISTING
CORNEAL OPACITY WITH CATARACT
Figure 5 shows a suggested algorithm to manage cataract
with corneal opacity.
DISCUSSION
Corneal opacities can make phacoemulsification difficult
and challenging. Evolution in keratoplasty techniques and
phacoemulsification has improved outcomes in these cases.
A thorough preoperative workup, appropriate patient
counseling, selection of an appropriate management mo-
dality, and close postoperative follow-up are essential to
ensuring optimum visual rehabilitation and patient
satisfaction.
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Disclosures: None of the authors has a financial or proprietary in-
terest in any material or method mentioned.
First author:
Namrata Sharma, MD
Rajendra Prasad Centre for Ophthalmic
Sciences, All India Institute of Medical
Sciences, New Delhi, India