Combining Keratoplasty and Cataract Surgery

With regard to the editorial by Dr. Rosen on combining keratoplasty and cataract surgery,1 I have to take exception. To the best of my knowledge, most patients in the United States with combined cataract and corneal disease have the triple procedure (penetrating keratoplasty, cataract extraction, and intraocular lens [IOL] implantation, performed simultaneously). Most of us achieve reasonably good optical results using the concept popularized by Binder,2 in which the surgeon uses his or her “usual” postoperative readings when doing the IOL calculations. If the patient has keratoconus and requires a contact lens postoperatively to correct high ametropia, acceptance is generally quite good. Refractive surgical procedures, particularly laser in situ keratomileusis (LASIK), appear to be very satisfactory treatment. The editorial's query, “What is the logic of combining the procedures?”, begs an answer. The logic of combining these 2 procedures is that the patient needs only 1 operation most of the time. The comment that “cataract and IOL surgery should surely be performed when the keratoplasty episode is complete” is probably valid from a purely refractive perspective. Functionally, however, I believe it is a bit unrealistic. Most patients in my practice would not be interested in achieving an incremental improvement in refractive error if it was at the cost of a mandatory second surgery. More important, cataract surgery places the endothelium of the transplanted cornea, in many cases already at a “competitive disadvantage,” at risk of developing late failure. Even in the best of hands, small incision cataract surgery damages some endothelial cells. Many patients with corneal grafts have severely compromised endothelia and still maintain graft integrity for many years. Is it really in their best interest to subject them to the increased risk of late graft failure for the sake of improving their refractive outcomes? While the description of Dr. Krumeich's technique was fascinating, I do not believe that it, in and of itself, should be the only thing that motivates us to combine these 2 procedures, which already work quite well when performed in unison. Randy J. Epstein MD Chicago, Illinois, USA