This document discusses the surgical management of cataract in patients with ectatic corneas. It addresses three main factors to consider: age of the patient, stage of keratoconus or corneal ectasia, and stability of the condition. For younger patients with mild, stable keratoconus, various imaging and biometry tools are recommended along with third generation IOL calculation formulas. For unstable conditions, cross-linking may be used to stabilize the cornea before surgery. Middle-aged patients with mild to moderate keratoconus can often proceed with standard biometry and formulas. More advanced or irregular cases may require additional corneal procedures before cataract surgery. Older patients generally tolerate cataract surgery better if their

1. No Financial interest
Ahmed El-Massry M.D.
Professor of Ophthalmology
Alexandria University
Egypt
Surgical
Management of Cataract in Ectatic Cornea
ESOIRS 2016

2. Main problem
IOL calculation and refractive outcomes in
Ectatic corneas

3. Three pillars
• Age
• Stage of Keratoconus or Ectasia in
general
• Stability

4. Age
• Young
• Middle aged
• Old age

5. Stage of Keratoconus
• Mild ectasia
• Moderate
• Severe

6. Stability
• Stable
• Unstable

7. In young patients : Till 35 years of age:
• With Mild treated Keratoconus and stable K readings:
1- Pentacam is mandatory.
2- Optical and Ultrasonic Biometry are essential
3- Third generation Formulae for IOL calculation:
- Haigis L
- Shammas
-Holladay 2
4- All results should be within two diopters of Haigis L
formula

8. Young patient with Cataract, Mild
Unstable KC
• Stability is a must
- Signs of Progression of KC:
1. Thinning of the cornea
more than ten microns per year.
2. Increase of the curvature
of the cornea more than one diopter per year.
3 . Increase the difference
between the superior and inferior meridia more
than one and half Diopters.

9. How to stabilize the irregular cornea
before cataract surgery
• Young patient before 30 years of age with
unstable cornea :
1- Stabilize the cornea by Corneal
Collagen Cross linking (CXL).
2- Pin hole test is essential :
If the vision improves: do CXL , CXL & ICRS –
• Wait three months and do cataract surgery

11. Middle aged cataract patient with
Stable Mild, Moderate KC
1- Pentacam is mandatory
2- Optical Biometry is reliable
3- Compare K readings in pentacam and Lenstar
or IOL Master.
4- Third generation Formulae like Haigis L .
5- Toric IOLs don’t have good results in irregular
Cornea.

12. Middle aged Cataract patient
“ 40-55years” with KC
• If the Ks are 52.00D- 55.00D :
Cornea l irregularity should be treated first:
-ICRS and wait for three months then :
- Pentacam
-Optical Biometry:
Haigis L Masket Shammas

13. Middle aged Cataract patient with
advanced KC
• Triple procedure:
DALK, Phaco and IOL
• Hydrops:
PKP and Catarcat extraction and IOL

14. Old age above 60 years and KC:
• Mild Keratoconus ; Kc1, with steep cornea mostly
Stable depend on the readings of Pentacam
• Moderate with Kc2, Kc3 : Make the surgery on
steps:
first : remove the cataract then assess the need
of the IOL especially when the powers of IOLs are
out of range…(-17.00 D , - 15.00 D IOL)

15. Old age with advanced KC
• Signs of advancement:
- Pachymetry less than 400 microns in the
center .
- K-max more than 60 D
- Endothelial folds
- History of Hydrops.
- Opaque apex.
• Standard PKP and Cataract and IOL

16. • Standard Ks
or
• depend on the other eye’s Ks and axial
length.

17. Cataract Post-Ectatic Cornea surgery
- Post Cross linking.
- Post ICRS.
- Post lasik, RK and cross linking.
- Post ICL
- Post PKP.

18. Post Cross Linking
• K readings considerations for Biometry.
• Not less than six months post CXL
• Cataract is hard !!!!!!

19. Post ICRS

20. Surgicaly
• No extra surgical skills
(Video Hoda Tolba)

21. Post RK, lasik and cross in the same case
• Biometry problems.
• Surgical difficulties as the cornea is not so stiff.
• Opened RK incisions.
• Wait long time after surgery for visual rehabilitation.

22. Post ICL

23. Post PKP
• Wait one year after PKP.
• Full explanation of rejection chance.
• Soft shell technique for endothelial protection.
• Small air bubble indicator for endothelial coating.
Day 1 postop

24. One day postoperative

25. Take Home Message
• Complete explanation to the patient.
• All preoperative investigations
(Pentacam, Manual Ks , specular
microscopy,……..)
• All plans and tools to protect the cornea.
• Correlate the age with the stability and stage
• Enough time for the compromised cornea to
heal.

26. THANK YOU
Bibliotheca of Alexandria

27. THANK YOU