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    Optimizing cataract outcomes when keratoconus is present

    With right diagnostics and vigilance, these eyes can achieve good visual outcomes

    Houston—Eyes with keratoconus present numerous challenges for cataract surgeons. Among these are stability, the potential need for crosslinking, and the long-term visual needs of patients with respect to spectacle or contact lens use, said Douglas D. Koch, MD. 

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    “Determining the IOL power and then managing the excessive postoperative refractive error of keratoconic eyes is a major challenge,” said Dr. Koch, professor and the Allen, Mosbacher, and Law Chair in ophthalmology, Cullen Eye Institute, Baylor College of Medicine, Houston. “If the eye is unstable, it may be best to crosslink and wait 3 to 6 months before proceeding with surgery.”

    IOL spherical power

    It is critical to try to determine if the patient’s cornea is stable or still changing and if corneal transplantation may be needed in the future, Dr. Koch said.

    Related: FDA approves one-of-a-kind IOL with extended range of vision

    “If patients are wearing glasses currently and are expected to wear glasses, there is no anticipated need for contact lenses or a corneal transplant,” he said. “We want to be as accurate as possible in calculating IOL powers.”

    In one case example, a 59-year-old male presented for cataract surgery. (Figure 1A)

    Dr. Koch used the Holladay formula on two different devices (IOLMaster and Lenstar), and aimed for a bit of myopia. (Figure 1B)

    Related: Wavefront-guided PRK after CXL for keratoconus

    This particular patient ended up hyperopic (0.91 with one device, and 1.12 with the other), which, is unfortunately very common, he said.

    “I have found that these eyes end up much more hyperopic than calculations would suggest, sometimes by over 2 D," he said.

    Two reasons this happens

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