Cataract surgery with corneal endothelial pathology

It is not uncommon for Fuch's endothelial corneal dystrophy (FECD) patients to present with a co-existent cataract. Surgeons are often faced with a choice between simultaneous and staged corneal and cataract surgery. Descemet's membrane endothelial keratoplasty (DMEK) has been found to have better visual outcomes as compared to Descemet's stripping endothelial keratoplasty (DSEK) and penetrating keratoplasty and is currently the preferred surgery for FECD. Endothelial cell count and pachymetry cutoffs were earlier used for decision-making. Various other investigations such as Scheimpflug imaging and confocal microscopy are now used to prognosticate the outcome when performing cataract surgery only. Triple DMEK has the advantage of a definite treatment in a single sitting. Whereas, a staged approach with DMEK followed by cataract surgery has a better visual outcome. This is due to variable refractive changes in the cornea post-DMEK or DSEK that can lead to inaccurate intraocular lens (IOL) power calculation. Even though the graft detachment rates and rebubbling rates have been found to be comparable in triple DMEK versus a staged surgery, in view of increasing patient demands and expectations for a spectacle-independent outcome, a staged surgery is now preferable. Conventionally, surgeons favored the use of only monofocal lenses; however, the use of premium IOLs, especially extended depth of focus lenses, is now increasing. In this review, we will discuss the various advantages and disadvantages of a simultaneous and staged approach and pearls on decision-making in FECD with cataracts.